Student / Volunteer Agreement Form (Page 3 of 3) in pdf

Student / Volunteer Agreement Form Page 3

CHILD PROTECTION STATEMENT OF ASSURANCE FOR

STUDENTS / VOLUNTEERS

I hereby give The Rumpus Room an assurance that I have not:

Been found guilty by a Court of a sexual offence or an offence against

the person of a student or child; or

Been dismissed from any previous employment on the ground that I

was involved in improper conduct of a sexual nature with a student or

child; or

Retired or resigned from my previous employment following allegations

that I was involved in improper conduct of a sexual nature with a

student or child; or

Been advised by any employer that my name has been included on a

list of those not to be employed in a child-related area of activity.

If you cannot give this assurance, you should not sign this statement. You

may however, wish to speak with the Director about the relevant occurrence.

If you sign the statement when you are not in a position to give such

assurance, the Preschool may terminate your services without notice.

Signature of Volunteer Helper: ____________________ Date: __________

(Upon completion, this form is to be filed in the Volunteers Register.)

Lea R ule – J anuary 2 014

Page 3

Last Updated – April 2015

Student / Volunteer Agreement Form Page 3