3150F.1

PINE BUSH CENTRAL SCHOOL DISTRICT

VOLUNTEER APPLICATION FORM/AGREEMENT

 

School Year:                               

Personal Information

Name:                                                                               Date:                                                             

Address:                                                                           Home Phone:                                                

Work Phone:                                                 

Cell Phone:                                                    

 Emergency Contact:                                      

Disclosure of Criminal Convictions

HAVE YOU EVER BEEN CONVICTED OF VIOLATING ANY LAW (EXCEPT TRAFFIC VIOLATIONS)?

YES _____ NO _____ If yes, attach summary of details. Disclosure of a criminal record does not automatically disqualify you from volunteer consideration. Your case will be judged on its own merits.

 

Employer

List below your current or most recent employer:

Date                             Name and location of employer                    Position and hours

____________          ________________________________      ___________________

 

Emergency Information

In case of emergency, please notify:

 

Name ________________________

Address ____________________________________ Phone _____________

 

Relevant Experience

List current and past volunteer experience, hobbies, interests, skills, or abilities:

_______________________________________________________________________________

_______________________________________________________________________________

 

What kinds of activities would you like to volunteer for?___________________________________

 

            Names of Children                       Building                              Homeroom Teacher   

    _____________________       _____________________     _____________________

 

    _____________________       _____________________     _____________________

 

    _____________________       _____________________     _____________________

 

    _____________________       _____________________     _____________________

 

    _____________________       _____________________     _____________________

 

Building(s) at which you would like to volunteer:   ____________________________________

I hereby certify that I am of good moral character and that the facts set forth in the above application form are true and complete to the best of my knowledge. I authorize investigation of all statements contained herein. I understand that false or misleading statements will be considered justification for disqualification.

 

Print Name:     __________________________________

 

Signature:         _________________________________    

Date: ___________________________

 

The Pine Bush Central School District does not discriminate on the basis of race, color, religion, national origin, age, sex, sexual orientation, or handicap in its educational programs, activities, or employment practices.

 

Reviewed by: ________________________________                           

Date: ___________________________

  Approved                     Not Approved