Volunteer Disclosure Statement

Code No. 905.1E1
Volunteer Disclosure Statement
It is the policy the Anamosa Community Schools Board of Education to make every reasonable effort
to provide a safe learning environment for students and staff working with volunteers. Therefore, the
District requires the following information from all Level 1 volunteers.
Current Date __________________________
School: _____________________ Teacher Last Name: ________________________
Please PRINT:
Volunteer ____________________________________________________________________
Legal First Name Middle Name Last Name
Address ____________________________ City __________ State_______ Zip ____________
Phone Number _________________ SSN ______________________ DOB ________________
Signature ______________________________ Date _________________________________
Reason for volunteering _________________________________________________________
Example: field trip, class party, classroom help, Watchdog
Do you have any record of alcohol or drug arrests? YES _____ NO _____
Have you ever been convicted of a felony? YES _____ NO ______
Have you ever been convicted, or had an administrative finding, of violating any law involving child
abuse, sexual abuse, physical abuse, sexual harassment or exploitation, or any other crime related to
children? YES _____ NO ______
Do you currently have charges pending to the offenses listed above? YES _____ NO ______
A standard background check will be completed for Level I volunteers.
The district office or designee will complete the following on all Level II volunteers:
A screening including Iowa Courts Online, Iowa Department of Corrections/Federal Bureau of Prisons
and Iowa Sex Offender Registry.
Background checks are good for five years from date of completion.
Approved 10/15/07
Revised 10/3/2011
Revised 1/16/12
Revised 8/17/15
Revised 6/5/17
Office use: Date form received in building __________