School Volunteer Application Form - Volunteer Code Of Conduct
ADVERTISEMENT
1
2
3N
S
D
ATIONAL
CHOOL
ISTRICT
Attachment #1
S
V
A
CHOOL
OLUNTEER
PPLICATION
2015-2016
Information provided on this form is confidential and will be used only for school Volunteer Program purposes.
Date:____________ School:____________________Teacher:__________________Student:________________
Last Name:_______________________First Name:_______________________Middle Name:_______________
Address:___________________________________________________________________________________
Street
City
State
Zip Code
Date of Birth:______________Home Phone:___________________Work/Cell Phone:______________________
Valid Form of Identification:
Drivers License / State ID / School ID (circle one)
Identification Number and State (ID #):___________________________________________________________
*Must attach copy of current photo identification
Do you have children or grandchildren in school?
_____Yes
_____No
Name:__________________________________School:_________________________Grade:____________
Name:__________________________________School:_________________________Grade:____________
Name:__________________________________School:_________________________Grade:____________
Do you have volunteer experience?
_____Yes
_____No
Where?____________________________________________________________________________________
Emergency Contact:
Name:_________________________________Phone:_________________Relationship:___________________
Name:_________________________________Phone:_________________Relationship:___________________
Do you have any criminal charges pending against you?
_____Yes
_____No
Have you ever been convicted of a felony?
_____Yes
_____No
Have you ever been convicted of a sex or drug related
offense or crime of violence?
_____Yes
_____No
Are you required to register as a sex offender under
Penal Code 290.95?
_____Yes
_____No
“I understand that the district may research my personal and professional background. I give my permission to have my
personal and professional references researched and hold the district and any individuals providing the district with
information harmless. I also understand that I may have a criminal history check run by law enforcement if I serve as a
volunteer. It is possible that as a volunteer I may have more than occasional or infrequent contact with students. Under Penal
Code 290.95 I am required to disclose to school officials if I am a registered sex offender. My failure to disclose this fact
could result in my arrest, prosecution, and likely fine and imprisonment. By placing my name below, I declare under penalty
of perjury, that I am not required, pursuant to Penal Code 290.95, to disclose to school officials that I am a registered sex
offender, and that I have not suffered convictions for sex or drug related offenses or for crimes of violence, and there are no
criminal charges pending against me. I agree to abide by the district’s safety and health rules and regulations.”
Signature:______________________________________
Date:____________________
Office Use Only: Background check cleared by:_____________________ Date:___________________
ML:______
SDSD:______
TB Test:________
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business