Chaperone Form

I also understand that while serving as a volunteer/chaperone I am responsible for the children under my care and I will refrain from smoking, drinking, profanity, ...
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$26e00

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Cash or Check (payable to school)

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VOLUNTEER/CHAPERONE FORM School District of Newberry County

PLEASE PRINT LEGIBLY School Name:

COMPLETE IN FULL Teachers Name: Social Security Number:

Last Name:

First Name:

Street Address:

Middle Name:

(Maiden Name):

Date of Birth:

Sex: (Please circle one) Female

City:

Email Address:

State:

Home Phone: (with area code)

Zip:

Cell Phone:

Male

(with area code)

Have you lived out of state within the last ten years? (Please circle one) Yes

No

If yes, which state(s)

Please read the following statement and sign the bottom ofthe form indicating you have read and agree with the statement regarding Volunteering in the School District ofNewberry County: • I wish to volunteer in the School District of Newberry County and do hereby certify that I have no medical issues . which would prohibit my ability to serve as a volunteer. • I also certify that I have no arrest history/legal issues which would concern the school district and that I understand that I am subject to backgroun~ investigation. I • also understand that while serving as a volunteer/chaperone I am responsible for the children under my care and I will refrain from smoking, drinking, profanity, possession of a weapon, and other behaviors not appropriate for the care of children. • I understand that while serving as a volunteer/chaperone I am obligated to participate with the entire group for the duration of the specific activity.

Volunteer/Chaperone Signature:

Date:

Principal Signature:

Date:

$26.00 Efectivo o cheque (a pagar en la escuela

FORMULARIO PARA VOLUNTARIOS/CHAPERONES

Distrito Escoiar del Condado de Newberry FAVOR ESCRIBIR EN IMPRENTA

COMPLETAR EN SU TOTALIDAD N ombre del maestro:

Nombre de la escuela:

N(1mero de seguro social: Apellido:

Primer nombre:

Direcci6n:

Segundo nombre:

(Apellido de soltera):

Fecha de nacimiento:

Sexo: (Circule una por favor) Femenino

Ciudad:

Email:

Estado:

Telefono en casa: (con el c6digo de area)

C6digo postal:

Telefono celular:

lHa vivido fuera del estado en los ultimos diez afios? (Circule uno)

Si

No

Masculino

(con el c6digo de area)

En que estado(s)

PorJavor lea la siguiente declaraci6n y firme la parte inferior delformulario indicando que usted ha lefdo y esta de acuerdo con la declaraci6n sobre el voluntariado en el distrito escolar del Condado de Newberry: e

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Deseo hacer un voluntariado en el distrito escolar del Condado de Newberry y certifico que no tengo problemas medicos que prohibirian mi habilidad para servir como voluntario. Tambien certifico que no tengo historial de detenci6n/problemas legales que le conciernan al distrito escolar y entiendo que estoy sujeto a investigaci6n de antecedentes legales. Tambien soy consciente que cuando sirvo como voluntario soy responsable por los ni:fios que estan bajo mi cuidado y me abstendre de fumar, beber, decir malas palabras, cargar armas, o cualquier otro comportamiento que no sea apropiado para el cuidado de los niiios. Entiendo tj_ue cuando sirvo como volnntario, estoy obligado a participar con todo el grupo por la duraci6n de la actividad.

Firma del Volunfario/ chaperon:

Pecha:

Firma del principal:

Pecha: