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Has your driver's license ever been revoked for any reason?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