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2016-2017 S.T.E.P Application
(Senior Tax Exchange Program)
Kewaskum School District has an obligation to its children and community to provide a safe and secure environment for all to learn and achieve their potential. With this obligation, we need to gather the following information for all applicants. Your replies on this application will not prohibit our consideration; however, any misrepresentation , falsification or omission of facts could result in your application to be denied for volunteering, chaperoning or the STEP program.
Full Legal Name (LAST)
Your answer
First
Your answer
Middle
Your answer
Gender
Must be 62 or older to qualify for this program
Maiden Name/Previous Married Name/s or Alias
Your answer
Current Address, City, State, Zip
Your answer
Previous Address, City, State, Zip (10 years or less, N/A if not applicable)
Your answer
Have you ever lived in another state? YES/NO, if yes please provide address, N/A if not applicable
Your answer
Phone #
Your answer
Email ( this will be used to notify you of the approval/denial of your application)
Your answer
Name/s of children/grandchildren and grades attending the school district:
Your answer
I am available:
I am available (check all that apply)
Required
I would like to help with: check all that apply
Required
Please check locations where you are willing to volunteer: check all that apply.
Required
Background History (to process your application, all answers must be completed.)
Your answer
Have you ever been cited or charged of a crime or a violation of the law, including traffic tickets?
If yes, Date/s of violations.
Your answer
If yes, name of court/jurisdiction where violation occurred?
Your answer
If yes, what was the nature of the offense?
Your answer
Are you on probation for any reason?
If yes, please explain N/A if not applicable
Your answer
Are there any pending criminal charges filed against you?
If yes, please explain.
N/A if not applicable
Your answer
STATEMENT AND AUTHORITY TO RELEASE INFORMATION PLEASE READ THIS STATEMENT CAREFULLY BEFORE YOU SIGN All information provided is true and correct to the best of my knowledge. I voluntarily authorize Kewaskum School District to obtain information from government agencies, law enforcement agencies, its officers and agents,corporations, schools, and any other agency warranted to obtain my criminal history. I voluntarily release the district, its employees, agents and providers of information from any liability related to furnishing and receiving information related to arrest and convictions or other offenses. I understand that as a volunteer my responsibility to the district with information I receive to do my duties about any student, staff or teacher is never appropriate topics for discussion outside of school. I understand that my volunteering is terminable at will, either by myself or by the Kewaskum School District regardless of the length of my volunteering.
Signature and Date
Your answer
For Office use only
Approve or Denied DATE
Your answer
For Office Use Only
Notified via email or phone
Your answer
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