Volunteer Information & Waiver of Liability Volunteer Information Form & Waiver of Liability Only one form needs to completed by a volunteer each school year. Please print clearly in link. Personal InformationName Last First Middle TelephoneAddress Street City State Zip Code Personal physician PhoneEmergency adult contact PhoneAre 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 OnlyGeneral 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*byonIs a criminal background check necessary ....If "yes" and provided the individual authorized the checkthe date on which the check was requested? the date on which it was received and reviewed Reviewed by:SignatureDate Δ
