ࡱ> Z]Y9 <bjbj@@ 4F*h*hnnThD(*'''''''$*{-T'i'U(WWW 'W'WW%h&pλ %'k(0(%-^- &&-&W''^(-nX :  Volunteer Application Form Name: _________________________ Date: ____________________ Address: ____________________________________________________________ City Zip Home Phone: _________________ Preferred Email: ______________________ Date of Birth: ____________ Place of Birth: ______________ % Male % Female Employer: ________________________ Job Title: _____________________ Work Address: _______________________ Work Phone: ____________________ Description of job duties: ______________________________________________ Volunteer areas of interest: Elementary Middle High School Specific school(s) and/or program(s) interest: ______________________________ Are you a member of an organization or group of volunteers? Yes No If yes, please specify the name of the organization/or group: _____________________. Describe your experience working with young people: ______________________ __________________________________________________________________. References: 1. _________________ _______________________ ________ __________ Name Address Phone Relation to volunteer 2. _________________ _______________________ ________ __________ Name Address Phone Relation to volunteer 3. _________________ _______________________ ________ __________ Name Address Phone Relation to volunteer In connection with your application to serve as a volunteer with Ӱ Public Schools, please answer the following questions: Mississippi House Bill 1340 requires any person who has been convicted of a sex offense who volunteers, or seeks to volunteer, for an organization in which volunteers have direct, private and unsupervised contact with minors to provide the organization with written notification of the conviction. Have you ever pled guilty to an offense other than a minor traffic violation? Yes No Have you ever pled  no contest to an offense other than a minor traffic violation? Yes No Have you ever been convicted of an offense other than a minor traffic violation? Yes No Do you have any pending charges, other than a minor traffic violation? Yes No If you answered  Yes to any of the above questions, please list the particular circumstances. Date LocationChargeCourtDisposition of Case   I understand that the Ӱ Public School District reserves the right to verify all information in this application and that any false statements or any failure to disclose information may be sufficient grounds to deny the request to volunteer. _____________________________________________________________ Volunteer Date Confidentiality Statement: The relationship between child and volunteer demands a high level of confidentiality. Volunteers may become aware of the problems and confidences of students, their parents and the school staff. These should never be discussed with anyone who does not have a professional right or need to know. If a volunteer suspects neglect, abuse, unlawful acts, or believe a students well-being is threatened, it becomes the duty of the volunteer to report the matter. 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H;;;;; 0$If]0gd@Pkd$$Iflr~RR&gmg t0&644 layt< ];kd>$$Iflr~RR&gmg t0&644 layt< ] 0$If]0gd@P;5-$a$gdB`0]0kd$$Iflr~RR&gmg t0&644 layt< ] 0$If]0gd@PSjk888999B:j:k:l:0;};xgddfgd!gd$a$gd ^`gdJGgddf$a$gd\gd?:$a$gd?: ^` & FPU8Y8c8q8{8}8˽ˬܬܛq]I&h"h"5CJOJQJ\^JaJ&h"h+"5CJOJQJ\^JaJ&h!h\5CJOJQJ\^JaJ&h!h+"5CJOJQJ\^JaJU h!h+"CJOJQJ^JaJ hk}h?:CJOJQJ^JaJhB`CJOJQJ^JaJ hk}h\CJOJQJ^JaJ hk}h+"CJOJQJ^JaJ#h!h?:CJ OJQJ\^JaJ I have read the above statement and will respect the confidentiality of the students and staff with which I will be working: ______________________________________________ ________ Volunteer Date I have received the application for this volunteer. 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