VIPS
Volunteers In Pampa Schools Application
Full Name
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Address
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City/State/Zip
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Phone Number
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Email
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Sex
Date of Birth
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Social Security #
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Check Boxes for areas of volunteer interest:
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Preferred schools
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During my volunteer placement with the Pampa Independent School District, I acknowledge that I may become aware of confidential education information relating to school staff or students. By signing this form I agree to in no way reveal or divulge any such information except if authorized by the campus principal or district administrator and to report child abuse or suspected child abuse immediately.
I hereby authorize any law enforcement agency, including a police department, the Texas Department of Public Safety and the Texas Department of Corrections, to release to Pampa Independent School District my complete criminal history record. I understand that Pampa Independent School District is prohibited by Federal Regulation from providing me a copy of my DPS criminal record;however, I further understand that, upon my request, the District may quote to me data from the report. Thereafter, I have the right to challenge the accuracy of my DPS criminal history report. I understand the information I am providing about age, sex, and race/ethnicity will not be used to determine volunteer eligibility, but will be used for the purpose of obtaining criminal history record information. Please sign below.
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I certify that I have read the above statement and the typed name is my official signature.
Date
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