Volunteer Application Form Page 2
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1. Please state the activity for which you would like to volunteer (i.e. book fair, PTO room parent, etc).
__________________________________________________________________________________________
__________________________________________________________________________________________
2. Do you have children/grandchildren in our district? _____ Children
_____ Grandchildren
3. Have you ever been the subject of a child abuse complaint?
_____ Yes _____ No
4. Have you ever been charged with or convicted of a felony or any crime involving minors? _____Yes _____ No
5. Have you ever lived in a state other than Pennsylvania within the last 10 years? _____ Yes _____ No
If you have not lived in Pennsylvania for the previous 10 years you are required to obtain Act 114 Clearance.
If so, where and what year:
State: ________________________________________
Years: ____________________________________
State: ________________________________________
Years: ____________________________________
6. Applicants may be asked by the Administration/Principal to obtain FBI fingerprint clearances in addition to the
documentation required below, new clearances must be obtained every three years.
Volunteer
TB
Act
Driver’s
Act
Principal
Act 114 if
Application
Test
34
License
151
Appoint-
not in PA
Form
Check
ment
for 10 years
Level I - Assistive
X
X
X
X
X
X
Level II - Independent
X
X
X
X**
X
X
X
Level III - Coaches/
X
X
X
X**
X
X
X
Sponsors*
Applicant Signature: _______________________________________________ Date: ___________________
**NOTE: Volunteers should review Jamestown Area School District’s Board Policy #916 on Volunteers.
__________________________________________________________________________________________
For Level III Applicants ONLY:
_____ I recommend this applicant for approval.
______ I do not recommend this applicant for approval.
Athletic Director Signature: ______________________________________ Date: _______________________
__________________________________________________________________________________________
For ALL Applicants:
_____ I recommend this applicant for approval.
______ I do not recommend this applicant for approval.
Principal Signature: __________________________________________ Date: ________________________
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