Junior High Volunteer Cover Sheet Page 2
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3Student’s Name ____________________________
TULSA PUBLIC SCHOOLS
VOLUNTEER APPLICATION
AND SECURITY CHECK
SCHOOL
DATE____________________
SITE
x
Last Name__________________________ First Name_____________________________ Middle Initial
x
SS#______________________ Date of birth__________________ E-Mail
x
Home Phone__________________________________________ Cell Phone
x
Current Address
x
City______________________________________ State________ Zip_______________ How long
x
Previous Address (if at current address less than 3 yrs.)
x
VOLUNTEER BACKGROUND QUESTIONNAIRE
Student and staff safety is of paramount concern to TPS. Please respond to the following questions truthfully and honestly. The disclosure of a prior
criminal history will not automatically prohibit selection as a volunteer.
1.
Have you ever entered a plea of guilty or no contest to a federal or state (any state) felony charge in a criminal proceeding?
Yes
No
2.
Have you ever been convicted of or found guilty of a federal or state (any state) felony offense?
Yes
No
3.
Have you ever been charged with a federal or state (any state) offense that was reduced to a misdemeanor offense to which you plead guilty or no
contest?
Yes
No
4.
Have you ever entered a plea of guilty or no contest to, or been convicted of, a federal or state (any state) misdemeanor charge including illegal
chemical substance or illegal sexual activity?
Yes
No
5.
Have you entered into a deferred prosecution agreement with a federal or state (any state) prosecutor? Yes
No
6.
Have you ever pled guilty or no contest to misdemeanor offense that was originally a federal or state (any state) felony charge?
Yes
No
7.
Have you ever been served with an Emergency Ex Parte Protective Order or any Protective Order in this or any other state for allegations of
harassment, abuse, domestic violence, stalking or threats to any person?
Yes
No
8.
Have you ever been taken into protective custody for being a threat to yourself or others or have you ever been ordered to mental health services
as a result of having been served with an Emergency Order of Detention or an Order of Detention for Mental Health from any Court evaluation?
Yes
No
If yes to any of the above, please provide explanation: __________________________________________________________________________
__________________________________________________________________________________________________________
Signature of volunteer_______________________________________ Today’s Date ________________
FOR SCHOOL USE ONLY
NOTE: This form MUST have the Principal’s signature before this application can be processed.
The information provided by the volunteer applicant has been checked against the databases of the following sites:
The Oklahoma State Court Network (OSCN)
Date Checked(__/__/__) by:______________
Oklahoma Department of Corrections
Date Checked(__/__/__) by:______________
Sex Offender Registry National
Date Checked(__/__/__) by:______________
Local
Date Checked(__/__/__) by:______________
Additional Background Check Requested: ___ Yes ___ No
_________________________________________
_____________________________
Principal’s Signature
Date
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