Park_Haven_Volunteer_Application by gegeshandong


									                                                                 PARK BUDDIES VOLUNTEER APPLICATION
Park Buddies: A Tutoring and Mentoring Program for Park Haven Children
Tuesdays & Thursdays 3:30-5:30pm
Beginning January10, 2012 thru May 31, 2012

           Contact Information: Principal Scott Taylor (763)561-6870 7400 Hampshire Ave. Brooklyn Park, MN

Thank you for your interest in serving as a volunteer with Park Haven. We appreciate your desire to contribute to the much
needed and anticipated Park Buddies Tutor/Mentor program. Please take a moment to fill out the following information.
Please return the form to the contact person and address above. If you have any questions you can contact that person as well.

Name: ____________________________________________________________________________________________________________________________

Street Address: __________________________________________________________________________________________________________________

City/State/Zip Code: ____________________________________________________________________________________________________________

Home Phone: ___________________________________________________       Work Phone: ______________________________________________

May we contact you during the day? □ Yes □ No

Email Address: __________________________________________________________________________________________________________________

Birthday (optional): ___________________________________________________

Employer/School: ______________________________________________________________________________________________________________

    1. Previous Volunteer experience: □ Never               □ Some Volunteer Experience □ Volunteer Leadership
                Volunteer Organizations:
    2. Why are you interested in volunteering?
    3. Please list 1-2 references, please include a name and form of contact:
       _________________________________________ _____________________________________________
       _________________________________________ _____________________________________________
       _________________________________________ _____________________________________________
    4. What days and times are you available to volunteer?
                □ Tuesdays 3:30-5:30pm                      □ Thursdays 3:30-5:30pm
    5. Would you be willing to create curriculum for this afterschool time program? □ Yes □ No

    To the best of my knowledge, the information included on this form is accurate and true. I authorize investigation of all
    statements contained in this interest form as may be necessary to arrive at a volunteer decision.

    Applicant’s Signature                                                                        Date

    Legal Guardian’s Signature (if applicant is under 18)                                        Date
    NOTE: The BACKGROUND DISCLOSURE portion of the volunteer application (attached) MUST be
    returned to school for your volunteer application to be complete.
                                                                                         BACKGROUND DISCLOSURE
Volunteer Name (please print):

Last Name                                                                       First                                        MI

This Background Disclosure page of the Park Haven Volunteer Application is a screening document. It will be reviewed by the
volunteer coordinator to determine whether or not a criminal history background check is needed. If a criminal history
background check is needed, you will receive a Background Authorization Investigation Form from your volunteer
coordinator. Submission of the Background Authorization Investigation Form is required before a criminal history
background check can be run.

This Background Disclosure page, which includes private data, will be stored separate from the first page of this Volunteer
Application in a secured location as designated by the principal of Park Brook or site leader.

This Background Disclosure portion of the Park Haven Volunteer Application MUST be returned to Park Brook Elementary
(7400 Hampshire Ave N Brooklyn Park, MN) for your volunteer application to be complete.

Are you a current ISD 279 employee? □ NO □ YES

        If ‘yes’: Employee ID Number: _____________ (If yes, sign and return this form with the scheduling sheet of the volunteer application.
        You do not need to complete the Consent and Acknowledgement section.)


If you are not a current ISD 279 employee, you must answer each of the following questions. Refusal to answer these
questions will result in denial of approval for you to volunteer at school. Based on responses to these questions and/or the
volunteer assignment for which you are considered, District 279 reserves the right to request a criminal history background
check (you will be notified if this is the case). The background disclosure section of the adult volunteer application and
information contained in it is PRIVATE and will only be shared with the volunteer coordinator, principal of Park Brook, site
leader, Human Resources, and/or people authorized by law to have access as needed.

1. Have you ever been arrested, charged or convicted of a criminal offense other than a minor traffic violation?

□ NO □ YES

2. Have you ever had any indicated finding of child abuse filed in your name? □ NO □ YES

3. Does your name appear on any Sex Offender Database in any state or country? □ NO □ YES

4. If your response to any of these three questions is ‘yes’, please answer the following questions:

        Has ISD 279 run a criminal history background check on you in your capacity as a volunteer in the past?
        □ NO □ YES

        If ‘YES’, please provide approximate date: _______________, and has anything changed in your background
        since the previously run criminal history background check? □ NO □ YES

    Applicants Signature                                                                         Date

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