Dansville Central School
Dansville Central School Volunteer Dansville Central Schools’ Volunteer Program Application 284 Main Street
Please complete this application as completely as possible and return to:
Dansville, New York (585) 335-4000 Name:
Phone Numbers:
Address:
E-mail: Previous or Current Occupation: Current Employer (if applicable): Do you have transportation: Do you have a valid driver’s license:
_______ Yes
_______ No
_______ Yes
_______ No
State / License No: Name of insurance carrier and limits:
I am especially interested in volunteering in this area or activity (i.e. classroom, projects, office, etc.): ___________ _____________________________________________________________________________________________ Grade Level Preferred:
Primary (Grades PreK-2) Elementary (Grades 3-6) High School (Grades 7-12)
Days / Times Available:
Monday at Tuesday at Wednesday at Thursday at Friday at
Have you ever been convicted or had adjudication withheld in a criminal offense other than a minor traffic violation, or are there any criminal charges now pending against you other than a minor traffic violation? _______ Yes _______ No Have you ever been convicted or pled guilty to a crime – either a misdemeanor or a felony (including but not limited to child abuse, theft, drug charges or other crimes of violence)? _______ Yes** _______ No
Dansville Central School Volunteer Application Page 2 of 5
**If yes, please explain in detail: _______________________________________________________________ __________________________________________________________________________________________ List all current and past volunteer experience / training (attach an additional sheet if necessary): ____________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________
List hobbies / interests: _________________________________________________________________________________________ _______________________________________________________________________________________________________________
Please describe any qualities, skills or abilities that you feel would make you a good volunteer to work with children: ______ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________
How long can you commit to a volunteer role with this school district? (please specify: one month, several months or one year): _______________________________________________________________________________________________________________
Please list three references (not relatives), preferably persons who can attest to your ability to work with others in a volunteer capacity: Name:
Phone Numbers:
Address: Relationship: Name:
Phone Numbers:
Address: Relationship: Name:
Phone Numbers:
Address: Relationship: I authorize all references listed to give you pertinent information, and release all parties from liability from furnishing this information. I attest that all information provided on this form is true and accurate to the best of my ability. I understand that any information provided that is found to be falsified is grounds for removal as a volunteer.
I have read and understand the volunteer handbook and agree to be bound by the terms and conditions outlined therein. Your signature indicates your willingness to comply with the policies of the Dansville Central Schools and to respect the privacy of the students and the issues of confidentiality that might arise during the time you are a volunteer in the schools.
Signature
Date Rev: 11/3/2016
Dansville Central School Volunteer Application Page 3 of 5
Foster Grandparent Program - Snow Day Procedure: There is not set number of snow days or limit. Snow days are called when the weather is considered severe enough that it is hazardous for our seniors to go to work. The decision is made by the Program Director. As with any absence, the FG is instructed to notify their site that they will not be in attendance. Please refer to the Snow Day procedure Policy. 1 Snow Day Procedure Policy When your school/site is closed for bad weather1: Automatic Snow Day When schools where you live are closed for bad weather: Automatic Snow Day When ground conditions are hazardous, a traveler’s advisory is in effect, low visibility and/or slippery, snowy roads: Snow Day-Call In When a temperature and/or wind chill factor is below zero and is not forecasted to warm up: Snow Day- Call In But if forecasted to rise into the teens or higher by mid-morning: Probably not an automatic snow day- Call in to find out Directional Snow day: The Director or Assistant Director will start the “calling tree” at 6:30am If the weather is bad, but clears and you go to work late: Partial Snow Day for the Time Missed- Call In In General: Listen to your local radio station for our program closing, we start to call radio stations around 6:30 a.m. and list our program as The Foster Grandparent Program of Livingston, Steuben & Wyoming Counties”. Use your own judgment on non-automatic days. If you feel it is dangerous for you to go to your school or site: STAY HOME. Please call and let us know, but we would rather have you all safe than sorry.1
1
Foster Grandparent Program of Livingston, Steuben and Wyoming Counties.
1
Also applies to district volunteers that are not Foster Grandparents.
Rev: 11/3/2016
Dansville Central School Volunteer Application Page 4 of 5
Rev: 11/3/2016
Dansville Central School Volunteer Application Page 5 of 5
Confidentiality Form
I, _________________________________, understand that I will be informed of confidential matters in regards to the children I work with at the volunteer sites. I understand that I will not repeat or discuss these matters with anyone else besides my assigned supervisor. I also am aware that even if I see one of the children outside of the volunteer site, I will not discuss my work with whomever they are with, nor discuss it with my family members. If I break this agreement I understand that I will be asked to leave the DCS Volunteer or Foster Grandparent Program. Any concerns regarding the children I work with will be directed to either my direct supervisor (building principal), or the Foster Grandparent Program Director.
Foster Grandparent / Volunteer Signature
Date
Foster Grandparent Director Signature or Building Principal Signature
Date
License has been run through The Raptor System.
Certified by: (please print and sign)
Date
Rev: 11/3/2016
Please complete this application as completely as possible and return to:
Dansville, New York (585) 335-4000 Name:
Phone Numbers:
Address:
E-mail: Previous or Current Occupation: Current Employer (if applicable): Do you have transportation: Do you have a valid driver’s license:
_______ Yes
_______ No
_______ Yes
_______ No
State / License No: Name of insurance carrier and limits:
I am especially interested in volunteering in this area or activity (i.e. classroom, projects, office, etc.): ___________ _____________________________________________________________________________________________ Grade Level Preferred:
Primary (Grades PreK-2) Elementary (Grades 3-6) High School (Grades 7-12)
Days / Times Available:
Monday at Tuesday at Wednesday at Thursday at Friday at
Have you ever been convicted or had adjudication withheld in a criminal offense other than a minor traffic violation, or are there any criminal charges now pending against you other than a minor traffic violation? _______ Yes _______ No Have you ever been convicted or pled guilty to a crime – either a misdemeanor or a felony (including but not limited to child abuse, theft, drug charges or other crimes of violence)? _______ Yes** _______ No
Dansville Central School Volunteer Application Page 2 of 5
**If yes, please explain in detail: _______________________________________________________________ __________________________________________________________________________________________ List all current and past volunteer experience / training (attach an additional sheet if necessary): ____________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________
List hobbies / interests: _________________________________________________________________________________________ _______________________________________________________________________________________________________________
Please describe any qualities, skills or abilities that you feel would make you a good volunteer to work with children: ______ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________
How long can you commit to a volunteer role with this school district? (please specify: one month, several months or one year): _______________________________________________________________________________________________________________
Please list three references (not relatives), preferably persons who can attest to your ability to work with others in a volunteer capacity: Name:
Phone Numbers:
Address: Relationship: Name:
Phone Numbers:
Address: Relationship: Name:
Phone Numbers:
Address: Relationship: I authorize all references listed to give you pertinent information, and release all parties from liability from furnishing this information. I attest that all information provided on this form is true and accurate to the best of my ability. I understand that any information provided that is found to be falsified is grounds for removal as a volunteer.
I have read and understand the volunteer handbook and agree to be bound by the terms and conditions outlined therein. Your signature indicates your willingness to comply with the policies of the Dansville Central Schools and to respect the privacy of the students and the issues of confidentiality that might arise during the time you are a volunteer in the schools.
Signature
Date Rev: 11/3/2016
Dansville Central School Volunteer Application Page 3 of 5
Foster Grandparent Program - Snow Day Procedure: There is not set number of snow days or limit. Snow days are called when the weather is considered severe enough that it is hazardous for our seniors to go to work. The decision is made by the Program Director. As with any absence, the FG is instructed to notify their site that they will not be in attendance. Please refer to the Snow Day procedure Policy. 1 Snow Day Procedure Policy When your school/site is closed for bad weather1: Automatic Snow Day When schools where you live are closed for bad weather: Automatic Snow Day When ground conditions are hazardous, a traveler’s advisory is in effect, low visibility and/or slippery, snowy roads: Snow Day-Call In When a temperature and/or wind chill factor is below zero and is not forecasted to warm up: Snow Day- Call In But if forecasted to rise into the teens or higher by mid-morning: Probably not an automatic snow day- Call in to find out Directional Snow day: The Director or Assistant Director will start the “calling tree” at 6:30am If the weather is bad, but clears and you go to work late: Partial Snow Day for the Time Missed- Call In In General: Listen to your local radio station for our program closing, we start to call radio stations around 6:30 a.m. and list our program as The Foster Grandparent Program of Livingston, Steuben & Wyoming Counties”. Use your own judgment on non-automatic days. If you feel it is dangerous for you to go to your school or site: STAY HOME. Please call and let us know, but we would rather have you all safe than sorry.1
1
Foster Grandparent Program of Livingston, Steuben and Wyoming Counties.
1
Also applies to district volunteers that are not Foster Grandparents.
Rev: 11/3/2016
Dansville Central School Volunteer Application Page 4 of 5
Rev: 11/3/2016
Dansville Central School Volunteer Application Page 5 of 5
Confidentiality Form
I, _________________________________, understand that I will be informed of confidential matters in regards to the children I work with at the volunteer sites. I understand that I will not repeat or discuss these matters with anyone else besides my assigned supervisor. I also am aware that even if I see one of the children outside of the volunteer site, I will not discuss my work with whomever they are with, nor discuss it with my family members. If I break this agreement I understand that I will be asked to leave the DCS Volunteer or Foster Grandparent Program. Any concerns regarding the children I work with will be directed to either my direct supervisor (building principal), or the Foster Grandparent Program Director.
Foster Grandparent / Volunteer Signature
Date
Foster Grandparent Director Signature or Building Principal Signature
Date
License has been run through The Raptor System.
Certified by: (please print and sign)
Date
Rev: 11/3/2016
