• 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