Emergency Contact and Background Check

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: ___________