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
