Volunteer Application Form - IJOC-R

M.S.A.D. #35

Superintendent of Schools’ Office

180 Depot Road, Eliot, ME 03903

Volunteer Application Form - IJOC-R

THE FOLLOWING INFORMATION IS REQUESTED TO HELP US COORDINATE VOLUNTEER SERVICES AND TO ENSURE STUDENT SAFETY.

Full Name: ___________________________________

All former names (maiden, married, and any alias used):

____________________________________________________________________________________________________________

Permanent Address: ________________________________________________________________

Telephone and Email: ________________________________________________________________

Date of birth (required for background check): _________________________________

Schools in which you will be volunteering:

☐ Eliot Elementary ☐ Central School ☐ MGWS ☐ MMS ☐ MHS

Area(s) of interest for volunteering:

Children in [name of school] (names and grades):

List any education, training, or experiences you have had which would help us in meeting the needs of our students:

References: List three persons who can comment on your character and abilities whom we may contact.

Name/Address-----------------------------------------------------------------------------Phone---------------Relationship

BACKGROUND:

The following information is asked of all individuals who volunteer to work with our children to help insure the safety of our students.

Have you ever been charged with or investigated for sexual abuse or harassment of another person? Yes__ No__

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

Have you ever entered a plea of guilty or “no contest” (nolo contendere) to any crime (other than a minor traffic offense)? Yes__ No__

Has any court ever deferred, filed or dismissed proceedings without a finding of guilty and required that you pay a fine, penalty or court costs and/or imposed a requirement as to your behavior or conduct for a period of time in connection with any crime (other than a minor traffic offense)? Yes__ No__

If you answered YES to any of the previous questions, provide full details below, including with respect to court actions, the date, offense in question, and the address of the court involved (attach additional page(s) if necessary).

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

If you have lived outside of Maine, please identify the states and dates:

Refusal to provide authorization for reference and/or criminal records checks and/or providing false or misleading information on this registration shall constitute sufficient reason to deny approval to serve as a volunteer or termination as a volunteer in the MSAD 35 district.

I understand that MSAD 35 performs reference and criminal records checks on all volunteers and I authorize persons and entities contacted by the School Department in connection with this application to provide information about me. I expressly waive in connection with any request for or provision of such information, any claims, including without limitation, defamation, emotional distress, invasion of privacy, or interference with contractual relations that I might otherwise have against the school department, its agents and officials or against any provider of such information. I further understand that if I am approved as a volunteer, that I will be required to sign a Volunteer Agreement and attend a Volunteer Orientation.

Signature of Volunteer: _____________________________________________ Date: _________________________

~~Date:~~

DISTRICT USE ONLY – PLEASE DATE AND INITIAL APPROVALS BELOW

Volunteer Agreement Form approved by Principal or Athletic Director: _____________________________

Volunteer Application Form approved by Principal or Athletic Director: _____________________________

Form reviewed for completeness and references checked by Principal or Athletic Director: ______________

Local report - Maine State Police Criminal History Check done by Superintendents’ Office and approved by Superintendents’ Office: _______________________________________________________________________

Maine Fingerprinting appointment confirmed: ____________________________________________________

Maine Department of Education Initial Approval Form submitted to Augusta, ME: _____________________

(Application Form Revised December 9, 2015)