904.3E1 - Volunteer Interest Information

SCHOOL _________________   NAME ____________________________________________ 

__ Parent    __ Non-Parent   __ Senior Citizen   __ Youth        DOB (mm/dd/yy) ____/____/____

Street Address_________________________________________________________________

City/State Zip______________________________________ Phone _____________________

 

Volunteer Disclosure Statement

It is the policy of the Independence Community School District Board of Education to make every reasonable effort to provide a safe learning environment for students working with volunteers.  Therefore, the district requires the following information:

Have you ever been convicted of a felony?  _____YES _____ NO

Have you ever been convicted, or had an administrative finding, of violating any law involving child abuse, sexual abuse, physical abuse, sexual harassment or exploitation, or any other crime related to children? _____ YES _____ NO

Do you currently have charges pending relating to any of the aforementioned?  _____ YES _____ NO

 

As a volunteer for the Independence Community School District, I understand that it is my responsibility to treat information about students, staff, and other situations of a professional nature as confidential.

 

Signature                                                                              Date