Volunteer Disclosure Sheet printable pdf download

920. ATTACHMENT (Rev.9/2/15)

School Year: _____________________ Building: ___________________________________________

Activity / Group: ______________________________

South Butler County School District

Volunteer Disclosure Sheet

(Program Volunteers and Overnight Chaperones)

In accordance with Policy 920 all volunteers must have a disclosure sheet on file in the building where services are

provided. Please complete the following information, and return it to the building in which you are

volunteering for the building administrator’s signature.

Name: ____________________________________________________________________________________

Address: __________________________________________________________________________________

__________________________________________________________________________________________

Phone: ______________________________________ Email: ______________________________________

Description of what you will be doing in the building: ______________________________________________

__________________________________________________________________________________________

Name of employee with whom you will be working: ________________________________________________

Building Administrator: _________________________________________

_________________________

Signature

Date

As a school volunteer you may become aware of information about a student and their family, which is

confidential. This can include grades, performance, skill levels, and other information shared in the classroom. It

is imperative that this information remains strictly in the classroom. I am not to discuss academic or other

confidential information regarding students or employees with anyone. Any breach of confidentiality will be

carefully reviewed and if substantiated could result in termination of volunteer involvement with the District, and

may result in legal action.

I agree that confidentiality of student information is critical and shall protect such information should I

become aware of it.

___________________________________________________

_________________________

Volunteer Signature

Date

I have received and reviewed a copy of the South Butler County School District Volunteer Policy, I

understand the procedures and responsibilities as a volunteer, and I agree to abide by them.

___________________________________________________

_________________________

Volunteer Signature

Date

Original: PINK

Copies: PINK

Volunteer Disclosure Sheet