Duval County Public Schools 2008/2009 Volunteer Application
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Please complete this application only if you do not have a valid Volunteer Identification Card. Volunteer Cards are good for two years from the date on the card. Completed applications may be returned to the school or directly to the Community and Family Engagement Office at the address below. The School
Volunteer Information sheet should be sent to the school only. Original signed applications are required. Please do not fax the applications.
Basic Information—Please Print Unreadable applications will not be processed.
*Required Information Please print in black or blue ink.
* Ms. Mrs. Mr. Dr. ______________________________________________________________________
First Middle Initial Last
* Former/Maiden Name(s): _______________________________________________________________
* Complete Street Address: _______________________________________________________________
Street City State ZIP
• Phone (home): ______________________ * (work): ____________________ (mobile): _____________
• Age: 18-20 years 21-61 years _ 62 years & over * Gender: Male Female
• List the name of the school or schools you would like to volunteer_______________________________
*Social Security # : _______ - ______ - ________ * Date of Birth : _______ / _______ / _____________
Note: In accordance with Florida Statute 119.071(5), Collection of Social Security Numbers, DCPS is required to notifyyou in writing the purpose for collecting your social security number. Social Security Numbers are imperative for theperformance of DCPS’s complete background screening process for volunteers who wish to volunteer in Duval County
Public Schools and will not be used for any other purpose.
Criminal Background
* Have you ever been arrested or issued a notice to appear in court for any alleged criminal infraction? Yes No
If yes, what was the alleged crime and the eventual outcome of your case? ______________________________________________________________________________________
By signing below, I affirm that the information provided in this application is true and correct to the best of my knowledge. I understand the information provided on this form will be used to conduct criminal background screening. Any falsification on this application may result in disciplinary action by school administration including termination of the volunteer relationship.
______________________________________________________________________________________
* Volunteer’s Signature * Date
Mail to:
Duval County Public Schools—Community and Family Engagement Office
1701 Prudential Drive, Room 614, Jacksonville, FL 32207
We love our volunteers!
Office Use Only
Listed Registered (F’printed) Cleared Rejected Processed _____ / _____ By: ________
Notes: _______________________________________________________________________________
Fletcher Middle School
“Surfing the Wave of Success”
School Volunteer Information
(This form gets turned in for the school to keep; the other form goes to the district office
for screening and is kept there for confidentiality reasons.)
Name: ______________________________________ E-mail: ___________________________
Day Phone: ________________________________ Evening Phone: _____________________
Age: 18-20 years 21-61 years _ 62 years & over * Gender: Male Female
Do you have children who attend/will be attending our school? Yes No
Child’s name: ______________________ Grade: _____ Teacher (if known): ________________
Child’s name: ______________________ Grade: _____ Teacher (if known): ________________
Availability/Interests
I would like to volunteer: once a month once a week more than once/week for special events/as needed
I would like to volunteer: Weekday Mornings Weekday Afternoons Evenings Weekends
I would like to volunteer as a: Mark all that interest you; those with an asterisk (*) may require fingerprinting
classroom assistant office assistant guest speaker special events planner/helper tutor*
field trip chaperone* mentor* other _____________________________
Health Information
Who should we contact in case of emergency?
Name: ____________________________ Relationship to you: ___________________________
Telephone: ______________________ ____________________ _________________________
home work mobile
Do you have any injuries, illnesses, or physical limitations we should be aware of? If yes, please describe.
_____________________________________________________________________________
Are you taking any medication we should be aware of in the event of emergency?
_____________________________________________________________________________
Do you currently have any contagious or infectious diseases? Yes No
If yes, you must provide a doctor’s statement verifying that you can work with the public.
Have you been exposed to TB? If yes, explain: _______________________________________
Please return volunteer forms to:
Fletcher Middle School – 6th Grade Office