Volunteer Application 1

VOLUNTEER APPLICATION AND INFORMATION FORM Part I
WASHINGTON COUNTY PUBLIC SCHOOLS

SCHOOL/LOCATION:_________________________
NAME:_______________________________________________________________________________
Information Required (Last) (First) (MI)
For
Verification of Clearance ALIAS/MAIDEN NAME:________________________________________________________________
(Please list all last names used)
Please print this
Information legibly so it DATE OF BIRTH:______________________ SEX:__________ RACE:________________________
can be read.
DRIVERS LIC # / STATE:______________________________________________________________
SPOUSE:__________________________________________ WORK #:__________________________
ALTERNATIVE CONTACT:_____________________________________________________________
HOME #:___________________________________ WORK #: ________________________________
Volunteer DOCTORS NAME:_________________________________ PHONE #:_________________________

Emergency Information
and contacts PREFERRED HOSPITAL:_______________________________________________________________
MEDICAL INSURANCE: YES NO INSURANCE COMPANY:_________________________

LIST ANY KNOWN HEALTH PROBLEMS:________________________________________________
____________________________________________________________________________________
ADDRESS:____________________________________________________________________________
(Street) (City) (State)
Volunteer Personal
HOME PHONE #: _____________________________ WORK PHONE #: ________________________
Information
for the school
VOLUNTEER JOB: ____________________________________________________________________
ROOM/TEACHER: ____________________________ CHILDS NAME: ________________________
I understand that my volunteer work may be contingent upon successful completion of a background check with the
Maryland State Police. I hereby certify that the information that I have given is true and accurate.
Signature of Volunteer: __________________________________________________________ Date:_____________
Drivers license verified by: _______________________________to check for correct birth date and spelling of name.
Date: _________________
Principal Approval_____________________________________ Date_______________

Volunteer will be working alone with students and needs criminal background check. Send application form to
Human Resource Department for processing, OR;
Volunteer will NOT be working alone with students. Place application form in school volunteer file. Do not forward
to Human Resources Department.
FOR HUMAN RESOURCES USE ONLY
This is to verify that the volunteer shown above has cleared the Maryland State Police background check.
Cleared: ______________________ Expires: ______________________ Verified by: _________________________
(Continued on reverse side)

WASHINGTON COUNTY PUBLIC SCHOOLS Part II
VOLUNTEER DISCLOSURE STATEMENT
Please answer YES or NO to each listed item. If the answer is YES to any item, explain in the
area provided, indicating the charge or finding, the date of the conviction or finding, the court(s)
involved, and the penalty imposed. I understand that the Washington County Public School
System may inquire of State and Federal law enforcement or other agencies and examine court of
agency records regarding my criminal history and civil adjudications.
1. Have you ever been convicted of any crime? Yes No
The term convicted means all adverse dispositions, including a finding of guilty, a plea
of guilty or nolo contendere, an Alford plea, stipulation to the facts, a deferred or
suspended sentence, or a deferred prosecution.
IF YES, PLEASE EXPLAIN BELOW.

_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
___________________________________________________
2. Have you ever had findings made against you for domestic violence, abuse, sexual abuse,
neglect, exploitation or financial exploitation of a child or vulnerable adult in any civil
adjudicative proceeding? Yes No
A civil adjudicative proceeding includes a judicial or administrative proceeding as well as

findings by the Department of Social and Health Services or the Department of Health that
you have not administratively challenged or appealed.
IF YES, PLEASE EXPLAIN BELOW.

_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
___________________________________________________
Any misrepresentations or omission of facts shall be grounds for denial of volunteer opportunities.
Affidavit
Pursuant to Maryland Annotated Code, Criminal Law Article 9-101, I certify under penalty of
perjury under the laws of the State of Maryland, that the foregoing is true and correct.
Print Name ____________________________________________

Signature ____________________________________________
Date ____________________________________________
Place ____________________________________________
NOTE: Please submit completed application form to Human Resources Department when criminal
background check is needed due to volunteer working alone with students. If criminal background
check is not needed, please file application form at the school-site where the volunteer will be
working. Applications submitted to Human Resources will be returned to the school site for filing
upon successful completion of the background check. (9/22/2009)

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VOLUNTEER APPLICATION AND INFORMATION FORM Part I

WASHINGTON COUNTY PUBLIC SCHOOLS

SPOUSE:________________ WORK #:

HOME #:___ WORK #:

Volunteer DOCTORS NAME:_________ PHONE #:_

MEDICAL INSURANCE: YES NO INSURANCE COMPANY:_________________________

ROOM/TEACHER: ____ CHILDS NAME:

Signature of Volunteer: ______________________________________________ Date:_

Principal Approval_______________________ Date_

FOR HUMAN RESOURCES USE ONLY

(Continued on reverse side)

1. Have you ever been convicted of any crime? Yes No

IF YES, PLEASE EXPLAIN BELOW.

A civil adjudicative proceeding includes a judicial or administrative proceeding as well as

IF YES, PLEASE EXPLAIN BELOW.

Print Name ____________________________________________

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