Newark Central Schools

Every Student, Every Day



Newark Central School District

Personal Information


 First Name____________________Middle Initial_____Last Name________________


Phone number______________



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












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