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Use back of form as needed. Garden Hills Homework Club Last DOB: Your Last Name Your First Name Middle Initial Date of Birth Street Address City_State_Zip Code_ Mailing Address if different: Day Phone # Email address Occupation EmployerPrevious experience working with children in Unit 4:When did you last volunteer with Unit 4? Provide month/year, staff s name and school:How do you want to assist/volunteer? Tutor an individual student or srnall groupDo clericalwork (Xeroxing, etc.) Mentor a student (l hl pgr weel< during school hours only) _Other (please list) Please indicate times and days you are available to volunteer: Monday Tr-resday Wednesday -Thursday -Friday Character References: Please list two non-family members who would be supportive of your working with children. Name Name _Assist as a general classroom aideHelo monitor lunclrroom or recess AddressErnail AddressErnail Day Pltone Day Phor-re Vo_luntee-r Releas e StatementHave you been convicted within the past ten years of any felony or misdemeanor classified as anoffense against a person or family; of public indecency; or of a violation involving a state or federallycontrolled substance? Yes No If yes' please explain:I hereby state that ifaccepted as a school district volunteer, I agree to abide by the rules andregulations of Champaign Unit #4. I understand that I rnay be subject to a criminal background checkTo the best of my knowledge and belief, all statements in this application are fiue and accurate. Signature Date For school use onlyAppl recd_ Blcgrd=MellonCLEARED Orientation Signed GuidelinesDatabase yesNovO7 THIS INFORMATION WILL BE KEPT CONFIDENTIAL 'tr<:tYou also need to complete a Criminal Background Clearance form and attend orientation before you volunteer. endstream endobj 7 0 obj 1856 endobj 8 0 obj << /Length 27 >> stream % CANON_PFINF_TYPE0_TEXTON endstream endobj 9 0 obj << /Length 44 >> stream q 612.24 0 0 791.76 0.00 0.00 cm /Obj2 Do Q endstream endobj 10 0 obj << /Type /Page /MediaBox [ 0 0 612.24 791.76 ] /Parent 11 0 R /Resources << /Font << /F3 5 0 R >> /XObject << /Obj2 2 0 R >> /Subtype 6 0 R /ProcSet [ /PDF /Text /ImageB /ImageC /ImageI ] >> /Contents [ 8 0 R 9 0 R 3 0 R ] >> endobj 11 0 obj << /Kids [ 10 0 R ] /Count 1 /Type /Pages >> endobj 12 0 obj << /Pages 11 0 R /Type /Catalog >> endobj xref 0 13 0000000000 65535 f 0000000015 00000 n 0000000110 00000 n 0000045286 00000 n 0000058642 00000 n 0000058664 00000 n 0000058767 00000 n 0000060676 00000 n 0000060697 00000 n 0000060775 00000 n 0000060870 00000 n 0000061119 00000 n 0000061185 00000 n trailer << /Size 13 /Info 1 0 R /Root 12 0 R /ID [] >> startxref 61240 %%EOF