INFORMATION TO BE SUPPLIED UPON EMPLOYMENT



VOLUNTEER APPLICATION

(FOR POSITION VOLUNTEERS ONLY)

Complete this form and necessary clearances for volunteer activities where you will be responsible for the care, supervision, guidance or control of children, and will have routine interaction with children. For further clarification, refer to the Volunteer Guidelines on the District’s website under the Departments tab. Begin this process at least three weeks prior to the activity in order for all clearances to be obtained. Submit this sheet, along with all necessary clearances, to the school’s main office. Please submit all documents together.

Name Gender Date of Birth Social Security # (last four digits)

___________________________________________________________________________________________

Address City State Zip Code

_____________________ _____________________ ____________________________________

Phone Cell Email

_________________ __________________ __________________________________________

School Year School Building Staff Member You Will Be Working With

___________________________________________________________________________________________

Volunteer Assignment(s)

Emergency Contact Information:

Name Phone Relationship

According to school district policy and Pennsylvania law, Position Volunteers are required to secure background clearances before the assignment may commence. There are three different types of background clearances: PA Child Abuse, PA Criminal, and the FBI Fingerprint. If you have lived in Pennsylvania continuously for 10 or more years, the FBI fingerprint background clearance may be waived if you are able to affirm that you have not been convicted of any crime, in another state, similar to the convictions listed on the back of this form.

Do you affirm that you have not been convicted of any crime, in this state or another state, similar to the convictions listed on the back of this form? □ Yes □ No

If you answered yes and have lived in PA for 10 or more years, you do not need to complete the FBI Fingerprint clearance. # of Years as a PA Resident ______________

After completing this form, submit this along with all necessary clearances to the school’s main office.

_______________________________________________________________ ___________________

Volunteer’s Signature Date

This section to be completed by Principal/Athletic Director □ Recommended □ Not Recommended

________________________________________________________________ ___________________

Principal’s/Athletic Director’s Signature Date

This section to be completed by Human Resources Background Clearances Required: □ Yes □ No

□ PA Criminal History □ PA Child Abuse History □ FBI Fingerprint

________________________________________________________________ __________________

Director of Human Resources Signature Date

Revised 08/2016

Pennsylvania Offenses or equivalent crimes under Federal law or the law of another state

1. Chapter 25 (relating to criminal homicide)

2. Section 2702 (relating to aggravated assault)

3. Section 2709.1 (relating to stalking)

4. Section 2901 (relating to kidnapping)

5. Section 2902 (relating to unlawful restraint)

6. Section 3121 (relating to rape)

7. Section 3122.1 (relating to statutory sexual assault)

8. Section 3123 (relating to involuntary deviate sexual intercourse)

9. Section 3124.1 (relating to sexual assault)

10. Section 3125 (relating to aggravated indecent assault)

11. Section 3126 (relating to indecent assault)

12. Section 3127 (relating to indecent exposure)

13. Section 4302 (relating to incest)

14. Section 4303 (relating to concealing death of child)

15. Section 4304 (relating to endangering welfare of children)

16. Section 4305 (relating to dealing in infant children)

17. A felony offense under section 5902(b) (relating to prostitution and related offenses)

18. Section 5903(c) or (d) (relating to obscene and other sexual materials and performances)

19. Section 6301 (relating to corruption of minors)

20. Section 6312 (relating to sexual abuse of children)

21. Section 6318 (relating to unlawful contact with minor)

22. Section 6319 (relating to solicitation of minors to traffic drugs)

23. Section 6320 (relating to sexual exploitation of children)

24. An offense designated as a felony under the act known as The Controlled Substance, Drug, Device, and Cosmetic Act.

25. An offense graded as a felony of the first, second, or third degree, other than one of offenses enumerated in #1 through #24 above, if less than ten years has elapsed from the date of expiration of the sentence for the offense.

26. An offense graded as a misdemeanor of the first degree, other than one of the offenses enumerated in #1 through #24 above, if less than five years has elapsed from the date of expiration of the sentence for the offense.

27. An offense graded as a misdemeanor of the first degree, related to driving under the influence of alcohol or controlled substance, if the person has been previously convicted of such an offense and less than three years has elapsed from the date of expiration of the sentence for the most recent offense.

28. The attempt, solicitation or conspiracy to commit any of the offenses set forth above

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download