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Volunteer Participation Request & Background Check Form
Prospective volunteers will receive consideration without
discrimination because of race, creed, color, sex, age,
national origin or disability.
Today's Date:
Volunteer Personal Information
Legal Name (First, Middle Initial, Last):
Student Name(s):
Teacher(s):
Address (City, State, Zip Code):
Home Phone:
Work Phone:
Cell Phone:
Volunteer Date of Birth:
Gender:
Male or Female
Race:
American Indian/Alaskan
Black
Multi-‐Racial
Asian/Pacific Islander
White
Activities you plan to volunteer for:
Please check ALL the activities you are expecting to volunteer for:
Field Trips
Field Days
Century Club
Classroom Volunteer
Emergency Contact Information:
Please list who we should contact in an emergency:
Name of Contact:
Relationship:
Phone:
Address:
Please list any medical information that may assist us in the event of an emergency:
Physician's name & number:
Allergies:
Current Medications:
Criminal Background History
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