VOLUNTEER APPLICATION
HEALTHY LEARNING ACADEMY
13505 W NEWBERRY RD,    NEWBERRY,  FL,   32669
352-372-2279,  352-372-1665(f)

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.


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 :

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)?  



Please Check One :  * 
Are there any current criminal charges now pending against you?
Please Check One :  * 
Have you ever been arrested and/or convicted for any sexually related crime?
Please Check One :  * 
Are you currently registered on any sex offender registry or been required to register as a sex offender?
Please Check One :  * 
Have you ever been arrested for and/or convicted for using or selling illegal drugs (including marijuana)?
Please Check One :  * 
Do you currently have any court orders and/or injuctions against you involving children?
Please Check One :  * 
Please Check One :  * 
Please Check One :  * 
Please Check One :  * 
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.