Form For Volunteer Position

Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Home Phone Number*

Please enter a valid phone number.

Work Phone Number

Please enter a valid phone number.

Duties for which you are Volunteering*

1. Are you presently being investigated or are you under a procedure to consider your discharge for misconduct by your present employer or have you offered a resignation to your previous employer? *

YesNo

Since you answered "yes" above, please explain the circumstances below.

2. Have you ever been reprimanded, disciplined, discharged, or asked to resign from a prior position?*

YesNo

Since you answered "yes" above, please explain the circumstances below.

3. Have you ever resigned from a prior position under circumstances involving your employer's investigation of sexual contact with another person, of mishandling of funds, or of criminal conduct?*

YesNo

Since you answered "yes" above, please explain the circumstances below.

4. Have you ever been charged with (or investigated for) sexual abuse of another person?*

YesNo

5. Have you ever been charged with, pled guilty or "no context" (nolo contendere) to, or been convicted of any crime involving sexual abuse of any person or any other crime of moral turpitude? (Moral turpitude is an act of baseness, vileness or depravity in the private and social duties which a person owes another member of society or society in general and which is contrary to the accepted rule of right and duty between persons, including, but not limited to theft, attempted theft, murder, rape, swindling and indecency with a minor.)*

YesNo

6. Have your ever been convicted of a crime, other than a minor traffic offense or ever entered a plea of guilty of a plea of "no contest" (nolo contendere), or has any court ever deferred further proceeding without entering a finding of guilty and placed you on probation, for any crime other than a minor traffic offense?*

YesNo

If you answered yes to any of the previous three questions, please explain, in detail, including the date of the charge, the court action, the offense in question, and the address of the court involved:

Conviction of a crime is not an automatic bar to volunteering. The district will consider the nature of the offense, the date of the offense, and the relationship between the offense and the position for which you are volunteering.

Any false or misleading information on this form shall be fully sufficient grounds to refuse to allow you to volunteer or, having been approved shall be cause for immediate dismissal.

My signature below constitutes authorization to check my background history, including without limitation, evaluations, criminal arrest and conviction record checks, reference checks, and release of investigatory information possessed by any private or public employer and state, local or federal agency. I further authorize those persons, agencies, or entities that the Rossville School

Corporation contact in connection with my volunteer application to fully provide the Rossville School Corporation any information, any claims, including without limitation, defamation, emotional distress, invasion of privacy, or interference with contractual relations that I might otherwise have against the Rossville School, its agents and officials or against any provider of such information.

Signature*

Date*

Date

Rossville Consolidated School Corporation does not discriminate against any individual because of race, sex, color, religion, national origin or handicap in any educational programs which we operate or in employment practices.

Administrative Signature

Date

Form For Volunteer Position

CRIMINAL RECORD