Volunteer Information & Waiver of Liability

Only one form needs to completed by a volunteer each school year. Please print clearly in link.

Personal Information
Name
Last First Middle
Telephone
Address
Street City State Zip Code
Personal physician
Phone
Emergency adult contact
Phone
Are you now or have ever been a school volunteer?
D.O.B
At which school(s)?
Year(s)?
The name of any child or ward attending this school
Information Regarding Criminal Conviction, Placement of DCF Child Abuse and ....
a) Are you a sex offender listed on a state or federal sex offender registry?
b) Are you listed on any DCF Child Abuse and Neglect registry?
c) Have you ever been convicted of a felony involving a minor?
d)
e) Have you ever been convicted of a felony?
If you answered YES to a), b), c), of d) above, ....
If requested, are you willing to consent to a criminal background investigation?
(The Superintendent or designee .... ).
Weaver of Liability
(The School District does not provide .... ).
Date
MM slash DD slash YYYY
Signature of Volunteer
Printed Name of Volunteer
************************************************************************
For School Use Only
General description of assignment(s)
- supervising students as needed by the teacher
- supervising students during a regularly scheduled activity
- assisting with academic programs
- assisting at the resource center or main office
- other
Other
"Sex offender list" checked*
by on
Is a criminal background check necessary ....
If "yes" and provided the individual authorized the check
the date on which the check was requested?
the date on which it was received and reviewed
Reviewed by:
Signature Date

Personal Information