Newark Central School District

    Personal Information


    First Name____________________Middle Initial_____Last Name________________


    Phone 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









    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