Newark Central Schools

Every Student, Every Day


 

VOLUNTEER PROFILE SHEET

Newark Central School District

Personal Information

 

 First Name____________________Middle Initial_____Last Name________________

 

Phone number______________

Address________________________________________________________________

 

Social Security Number___________________________________________________

 

License Number_________________________________________________________

 

Chaperone______   Classroom Volunteer ________Other_________________________

 

Description of Volunteer Duties

 

Have you previously volunteered in the Newark Central School District?

Yes ____No___

 

 

If yes, which Teacher_____________________  Building__________ Dates of Service_______

 

If  no, which Teacher______________________Building _________________are you requesting to volunteer.

 

 .  

Are you currently employed?   Yes__________    No_______

If yes, may we contact your present employer?    Yes_________    No_________

 

If yes, please provide a name and phone number for us to contact________________________________________________________________

 

Medical Records

 

Do you have any impairments, physical, mental or medical, which would prevent you from performing in a reasonable manner the activities involved in the volunteering positon for which you are applying?  Yes______   No_______

 

If yes, please explain:___________________________________________________

 

 

 

 

 

 

 

 

References:  Please list 3 persons not related to you.  References will be checked.

Name                                                Address                    Phone              Years Known

 

 

      ________________________________________________________________________

 

________________________________________________________________________

 

 

 

 

 

Background

Have you ever been convicted of a crime (other than a minor traffic offense or violation)?

 

Yes________ No___________

 

If yes, please explain:_____________________________________________________

 

Have you ever been the subject of an “indicated report” filed with the statewide register of child abuse and maltreatment?  Yes_____    No______

 

If yes, please explain: ____________________________________________________

 

Have you ever been the subject of or the respondent in a child protective proceeding where the court issued a finding of abuse and/or neglect of a child?   

Yes____   No______

 

If yes, please explain: ______________________________________________________

 

I certify that all statements made by me on this application are true and complete.  I understand that any false or misleading statements made by me will be considered justification for disqualification of my application or termination of volunteer status.                         

 

 

Applicant’s Signature_________________________________ Date_________________

                                              Newark Central School District

Debora Barry, Volunteer Coordinator  

625 Peirson Ave. Newark, NY  14513

  315-332-3265/fax 315-332-3359

 

 

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