Leu Civic Center, Inc
A United Way Agency
213 N. Market Street, Mascoutah, IL 62258
(618) 566-2175
leuciviccenter.net
Emergency Contact Information
I _______________________________ give my permission to the staff of the Leu Civic Center, Inc. to contact the following person(s) in case of an emergency while volunteering at the LCC.
Emergency Contact: ________________________________ Phone: ___________
Street Address: ______________________________________________________
Emergency Contact: ________________________________ Phone: ___________
Street Address: ______________________________________________________
Background Check Release
Name:______________________________________ MI _____ DOB_________
Current Address:____________________________________________________
Other than a traffic violation, have you been arrested, convicted and/or charged of a crime? ___Yes ___No if yes please explain: _________________________ __________________________________________________________________
Background checks are required for all individuals working with children. Copy of Driver’s License or State ID required.
Signature: _________________________________________ Date: ___________