VOLUNTEER APPLICATION

OKALOOSA COUNTY SCHOOL DISTRICT
COMMUNITY AFFAIRS
120 LOWERY PLACE SE,     FT. WALTON BEACH,   FL,   32548
850-833-7614  850-301-3065(f)
meredithd@mail.okaloosa.k12.fl.us


NAME :  *  *
SOC. SEC. NO. :
ADDRESS :   *
 
  *   *   *
HOME PHONE :
 
WORK PHONE :
  
CELL PHONE :
*
DRIVER'S LICENSE : * *
E-MAIL ADDRESS :   *
CONFIRM E-MAIL ADDRESS :   *
DATE OF BIRTH :  *
US CITIZEN :
      
GENDER :       *
EMERGENCY CONTACT :
Organization :
School or District Employee :      *

Please check all schools that you wish to volunteer at. *














Please check volunteer activities that is of interest to you.  *




Please check volunteer levels that are of interest to you.  *

Coach Mentor Chaperone Overnight Chaperone Classroom/School Volunteer

If you select Coach, Overnight Chaperone, or Mentor from the list obove you will also be required to contact the Office of Community Affairs at the Okaloosa County School District at 850-833-7614 and schedule a time for you to come to the office for fingerprinting.    


I AM AVAILABLE ON :  *


Monday
           


Tuesday
           


Wednesday
           


Thursday
           


Friday
           


VOLUNTEER ETHNICITY – PLEASE CHECK ONE :


PLEASE CHECK OTHER LANGUAGES WHICH YOU KNOW :

























Volunteer Experience/Talents
  
Languages/Skills or Hobbies :

If you can answer "Yes" to any of the following questions you must mark yes below. 
  1. Have you ever been convicted, found guilty, entered a plea of nolo contender (no contest), entered into a deferred prosecution or pre-trial intervention agreement, or had adjudication with held in a criminal offense other than a minor traffic violation (DUI is not a minor traffic violation). 
  2.  Are there any current criminal charges now pending against you?
Please Check One :  * 

If you can answer "Yes" to any of the following questions you must mark yes below. 
  1. Have you ever been arrested for and/or convicted for any sexually related crime?
  2. Are you currently registered on any sex offender registry, or been required to register as a sex offender?
Please Check One :  * 

If you can answer "Yes" to any of the following questions you must mark yes below. 
  1. Have you ever been arrested for and/or convicted for DUI / DWI (driving under the influence and/or driving while intoxicated)? 
  2. Have you ever been arrested for and/or convicted for using and/or selling illegal drugs (including marijuana)? 
Please Check One :  * 

If you can answer "Yes" to any of the following questions you must mark yes below. 
  1. Do you currently have any court orders and/or injunctions against you involving children?
  2. Are you the subject of any form of court ordered injunction that restricts your access to any student or school in the Okaloosa County School District?
Please Check One :  * 

I understand that as a participant in the Mentor or Volunteer Program, contact with students is only to take place while at school and/or during school-related activities.  Any attempts to communicate or make contact with students by mentors/volunteers outside of school are strictly prohibited.  
Please Check One :  * 

I understand it is the policy of the School Board of Okaloosa County to offer students the opportunity to participate in appropriate programs, services, and activities without regard to race, color, religion, sex, age, national or ethnic origin, political belief, marital status, parenthood, pregnancy, disability, sexual orientation, or social and family background. (Equity Policy)

Please Check One :  * 

I understand and will comply with the following:

Students, while they are in school or participating in school-related activities, are entitled to an environment free of discrimination and/or harassment by other students or adult employees or volunteers.  Students should not be subjected to nor should they subject others to:
  1. slurs or innuendoes about any characteristics listed in the Equity Policy above;
  2. any activity or talk related to the equity policy above that creates an offensive educational environment or unreasonably interferes with the individual’s school performance or participation in educational opportunities;
  3. sexual advances, requests for sexual favors, or physical conduct of a sexual nature.
Please Check One :  * 

I understand and will comply with the following:

All employees and volunteers are expected to work with other employees, to teach students, and to supervise or to be supervised in their work by other employees without regard for race, color, religion, sex, national or ethnic origin, age, marital status, or disability.

Please Check One :  * 

I understand and will comply with the following:

Drug Free Workplace

  1. The school district complies with the Drug Free Workplace Act of 1988 to maintain a drug-free workplace. The “workplace” shall be defined by U.S. Code and Code of Federal Regulations - as amended from time to time. 
  2. Each employee and the public is hereby notified by this policy that the unlawful manufacture, dispensing, possession, distribution, or use of a controlled substance or alcohol is strictly prohibited at any and all work sites or work related functions or as a part of any school activity, or any function held on school board property.
Please Check One :  * 

I am aware that for the protection of students, the Okaloosa County School District requires and conducts FDLE Sexual Offender and Predator screenings on all volunteers.  National and Florida Department of Law Enforcement background checks are conducted on all school mentors and spot background checks on school volunteers.  In addition, volunteer coaches and overnight field trip chaperones will be fingerprinted.  I hereby approve of such a check on my background. 

I am also aware that Social Security Numbers shall be collected from District volunteer program applicants for:

(a) Initial background screening not requiring fingerprints for any volunteer applicant who declares, or has had, a prior arrest; and, 

(b) For full criminal background screening (Level II Screening- §435.04, Fla. Stat.) for service as a one-on-one mentor, over night field trip chaperone, volunteer coach, or random applicant volunteer screening.

Please Check One :  * 


Address of Past 5 years :
Dates at this Address Address

Alias and/or married names:

List Three (3) References:
Reference Reference Name Email Address Phone Cell Phone
#1
#2
#3
      
Answer Confirmation.... X
   
Please review your answer and check that this is the correct answer that you wish to provide.
 
   

 
Thank you for offering your time, talents and skills to enhance the education of our students.

Thank you for your interest in serving as a school volunteer or mentor. For the protection of our students, the Okaloosa County School District requests a response from each school volunteer to the items in this form. Volunteers will be asked to complete a new Volunteer/ Mentor Affidavit each school year.