Student Safety Acknowledgement + Disclosure
Volunteers 18 or older must complete this form for each school year that they wish to work with students at Portland Community Squash.
Name
*
First Name
Last Name
Email
*
example@example.com
Phone
*
-
Area Code
Phone Number
Member Date of Birth
-
Month
-
Day
Year
Date
Student Protection Plan Acknowledgement
I acknowledge that I received, reviewed, and understand the Portland Community Squash Student Protection Plan. I had an opportunity to ask questions about the plan and agree to uphold the standards in the plan.
Signature
*
Self-Disclosure of Criminal Record
Do you have any currently pending arrests or accusations? Have you been convicted of a crime in the past year?
*
Yes
No
If yes, please explain below:
Signature
*
Self-Disclosure of Changes to Driving Record
In the past year, have there been any changes to your driving record? If yes, please explain below:
*
Yes
No
Type a question
Signature
*
Submit
Should be Empty: