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2018-2019 S.T.E.P Application
(Senior Tax Exchange Program) MUST BE 62 or older and live in Kewaskum School District)
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.
ARE you 62 years or older and Do you live in the school district of Kewaskum? (if no to either question you are not eligible for the STEP program, please complete the adult volunteer application.)
Last Name *
Your answer
First Name *
Your answer
Middle Name *
Your answer
Maiden Name/Previous Married Name/s or Alias (NA if not applicable) *
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
Home or Cell Phone Number *
Your answer
Email (this will be used to notify you of the approved/denial of your application) *
Your answer
Names of children/grandchildren and grades attending the Kewaskum School District, N/A if applicable. *
Your answer
Times I am available : (during/after school, specific times) *
Your answer
I am available :(check all that apply) *
Required
I am willing to help with: (check all that apply) *
Required
I am willing to help at : (check all that apply) *
Required
Background History (to process your application, all answers must be completed.)
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 applicaple *
Your answer
Are there any pending criminal charges files against you? *
If yes, Please explain *
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. I agree to release the district of any obligation should I be come ill or receive an injury as a result of my volunteer services.
Signature *
Your answer
DATE: *
MM
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DD
/
YYYY
For Office Use Only
Approved or Denied (date)
Your answer
Notified via email or phone
Your answer
Legal References
policy 3121,8120 The Kewaskum School District does not discriminate on the basis of sex, race, color, religion, creed, age, national origin, ancestry, pregnancy, marital status or parental status, sexual orientation, or disability. For more information view nondiscrimination clause or visit www.kewaskumschools.org.
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