District 96 Volunteer Information Form & Waiver of Liability

District 96 Volunteer Information Form & Waiver of Liability

ALL SCHOOL VOLUNTEERS MUST COMPLETE THIS FORM ANNUALLY.

Only one form needs to be completed by a volunteer for all schools in District 96. Please print clearly and in ink.

Full Name (Last, First)*

Phone #*

Phone

Address (Include Street / City / State)*

Email Address*

Emergency Adult Contact Name (Last, First)*

Personal Physician's Name (Last, First)*

Physician's Phone #*

Phone

Student Name*

Attending School*

Select

Student Name

Attending School

Select

Are you now or have you ever been a school volunteer in District 96?

Select

Have you ever been convicted of a criminal offense other than a minor traffic violation?*

YES

If you have been convicted of a criminal offense other than a minor traffic violation, explain, giving dates:

Have you ever had any indicated finding of child abuse filed in your name?*

YES

If you have ever had any indicated finding of child abuse filed in your name, explain, giving dates:

Does your name appear on any Sex Offender Database in any state or country?*

YES

Waiver of Liability**

The School District does not provide insurance coverage to non-District personnel serving as volunteers for the School District. The purpose of this waiver is to provide notice to prospective volunteers that they do not have insurance coverage by the School District and to document the volunteer’s acknowledgment that they are providing volunteer service at their own risk.

By checking the "I agree to items A, B and C" box below:

A) You acknowledge that the School District does not provide insurance coverage for the volunteer for any loss, injuries, or death resulting from the volunteer’s unpaid service to the School District.

B) You agree to assume all risk for death or any loss, injury, illness, or damage of any nature or kind, arising out of the volunteer’s supervised or unsupervised service to the School District. You also agree to waive any and all claims against the School District, or its officers, School Board Members, employees, agents or assigns, for loss due to death, injury, illness or damage of any kind arising out of the volunteer’s supervised or unsupervised service to the School District.

C) You confirm that all of the above answers are complete and truthful.

I agree to items A, B and C

I do not agree to items A, B and C

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