Home | Policy Book | I

IJOC-E

MSAD 71 Volunteers

Name______________________________________ Date of Birth___________

Address__________________________________________________________

Town__________________________________State__________ZIP_________

Home Phone______________________ Business Phone___________________

Driver’s License Number and State____________________________________

Email Address_____________________________________________________

Confidentiality and Ethics Statement

As a volunteer for MSAD 71, I understand that I have an obligation to maintain the highest level of ethical conduct.  I agree to preserve the confidentiality of any or all information regarding MSAD 71 students, staff, and any other related party, and will refrain from engaging in activities that would prejudice my ability (or the ability of others) to carry out my volunteer duties ethically, including violation of criminal or civil laws.

Signature____________________________________ Today’s Date___________

Criminal History

1. Have you ever been charged or investigated for sexual abuse or harassment?

Yes___

No ___

2. Have you ever been convicted of a crime or pleaded “no contest” to a crime (other than a minor traffic offense)?

      Yes___

             No ___

If you have answered “Yes” to either of the above questions, please explain on a separate sheet.  Prior criminal history is not an automatic bar to volunteer service.  All information will be treated confidentially.

I attest that the above statements are accurate and true to the best of my knowledge.  By my signature, I authorize MSAD 71 to check criminal and/or civil records. 

Signature__________________________________Today’s Date_____________________  

Thank you!