903.2E2 VOLUNTEER DISCLOSURE STATEMENT

It is the policy of the Tipton Community School District Board of Education to make every reasonable effort to provide a safe learning environment for students working with volunteers. Therefore, the District requires the following confidential information from volunteers who work directly with students or assist staff on a regular basis, supervise/chaperone students or act as a primary authority figure. This statement must be completed and returned to the school building office prior to beginning any volunteer experience.

Have you ever been convicted of a serious misdemeanor, aggravated misdemeanor, or felony under Iowa law or any other state/country law?

                          Yes                                                          No

Have you ever been convicted, or had an administrative finding, of violating any law involving child abuse, sexual abuse, physical abuse, sexual harassment or exploitation, or any other crime related to children?

                          Yes                                                          No

Have you ever been the subject of or listed as the perpetrator in a founded child abuse report?

                          Yes                                                          No

Are you required to register as a sex offender with the Sex Offender Registry?

                          Yes                                                         No

Do you currently have charges pending or are there any ongoing investigations relating to any of the aforementioned?

                          Yes                                                          No

Has your driver's license ever been revoked for any reason? (Answer to be used in determining volunteer drivers.)

Yes                                                           No

A "Yes" answer  to any of the questions listed above requires an interview with a district administrator.

 

Name:  ________________________________________________ (Print Name)                                                                                                                                                                                              

Street Address:   ________________________________________       City/State/Zip:  __________________________________________                     

Day Phone:  __________________________________                 Evening Phone:  _____________________________                                                              

School in which you wish to volunteer:  elementary               middle                   high (one school per form)

By signing this form, I agree that should any of the above information change in the future I shall contact the school building principal immediately.

Volunteer's Signature:  ___________________________________________                               Date:  _______________________                                  

Building Principal’s  or Activities Director Signature:  _____________________________________   Date:  _______________________                               

Please return this form to:  Tipton Community  School  District, Office of the Superintendent, 400 E 6th St., Tipton IA 52772

Approved:  12/11/1995                                Reviewed: 3/8/2021                                 Revised: 3/8/2021