2019-2020 Kewaskum School District Volunteer/Chaperone Background Application
This application is for adult volunteers (including field trip chaperones) for the Kewaskum School District. See other application forms on our district website for student and STEP programs.
The Kewaskum School District has an obligation to its children and community to provide a safe and secure environment for all students. Furthermore, the Board of Education recognizes that certain programs and activities can be enhanced through the use of volunteers who have particular knowledge or skills that will be helpful to members of the staff responsible for the conduct of those programs and activities. Any individual who volunteers to work in the schools or on any school-sponsored activity shall submit to (and approved) a criminal history records check which includes screening from the Sex Offenders Registry, prior to being allowed to participate in any activity or program (policy 8120). There may be a fee for out of state background check processing.
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 street address, city, state, zip *
Your answer
List previous addresses, city, state, zip (within the past 5 years): *
Your answer
List previous OUT OF STATE addresses, city, state, zip (within the past 5 years): *
Your answer
Current Phone Number: *
Your answer
Email Address: *
Your answer
Date of Birth (mm/dd/yyyy): *
MM
/
DD
/
YYYY
I prefer to volunteer/chaperone at:
I prefer to volunteer/chaperone at:
I prefer to volunteer/chaperone at:
I prefer to volunteer/chaperone at:
I prefer to volunteer/chaperone at:
Names of children/grandchildren and grades attending the Kewaskum School District (if applicable): *
Your answer
I have not been convicted of, or pled guilty or no contest to any crimes and I do not have any pending criminal charges filed against me. *
I have been convicted of or pled guilty or no contest to, the following crime(s) (include any pending criminal charges filed against you -do not include minor traffic violations). Explain nature of conviction, date and court. (NA, if not applicable): *
Your answer
I am interested in: *
Required
I am interested in volunteering in these areas (NA) if not volunteering: *
Required
Authorization and Release for Record Check
I understand and agree that pursuant to the law, the Board of Education must request a criminal history check on me; until that report is received and reviewed by the District, I am not regarded as a volunteer; and if the report received is not the same as my representation(s) above respecting either the absence of any conviction(s) or any crimes of which I have been convicted, my application is voidable at the option of the District.

I shall agree to abide by all Board policies and District guidelines while on duty as a volunteer; I understand I will be covered under the District's liability policy but the District cannot provide any type of health insurance to cover illness or accident incurred while serving as a volunteer, nor am I eligible for workers compensation; I release the District of any obligation should I become ill or receive an injury as a result of my volunteer services; in accepting the role of a volunteer, I agree to verification that a satisfactory background check will be conducted through appropriate State agencies or other applicable means.
I agree to the above Authorization and Release for Record Check *
Required
Date Agreed/Submitted: *
MM
/
DD
/
YYYY
Submit
Never submit passwords through Google Forms.
This form was created inside of Kewaskum School District. Report Abuse - Terms of Service