Volunteer Ichat Registration Form

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4120.09F
Volunteer ICHAT Registration Form
Byron Area Schools
Byron, Michigan 48418
Teacher/Organization ___________________
The Byron Area Schools Board of Education recognizes that volunteers can provide valuable services in helping
the school district deliver educational programs for all students. The Board also recognizes its’ responsibility to
the students of the district to make sure that their best interests are pursued at all times. To that end, all regularly
scheduled volunteers are asked to fill out this form and approval of the building administrator will be required
before a volunteer can be utilized.
Please answer the following questions:
Have you ever been convicted of a felony? ____Yes ____No
If "Yes," when/what/where? ______________________________________________
Are you currently involved with any court orders or pending legal action? ___Yes ___No
Are you currently, or have you been, involved in substance abuse rehabilitation in the previous five years?
____Yes ____No
Will you abide by the Policies adopted by the Byron Board of Education? ____Yes ___No
I attest that all of the above statements are true.
Name (please print)
Last
First
Middle Initial
Street Address_________________________________ City______________ Zip Code _______
Race
Sex: Male
Female
Birth date ______ ______ ______
Birthplace _____________________________ _______
Month
Day
Year
City
State
Maiden Name: _________________________
(_____)________________________________
Phone Number (Area Code must be included)
Please list two references that the Building Administrator can contact to verify your statements:
#1.
Name
________________________________________________________________
Address ________________________________________________________________
City
___________________________ State ______ Phone #: _________________
#2.
Name
________________________________________________________________
Address ________________________________________________________________
City
___________________________ State ______ Phone #: _________________
Signature __________________________________________________
Date ______________
References verified by ___________________________________
Date __________________
C:\Documents and Settings\bcoklr\Local Settings\Temporary Internet Files\OLKD\Volunteer Registration Form.Ichat.2.doc
Revised 8/20/09

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