Volunteer Application Form - PACT Charter School

Volunteer Application Form
Last Name__________________________________ First Name _________________________
Address____________________________________ City________________ Zip_______
Please give as much information as need to contact you easily.
Daytime phone #: ____________________
Work home
Evening phone #: ____________________
Work home
Other (cell, pager, etc.) (___) ________________E-mail___________________________________
Preferred form of contact: home phone work phone e-mail cell phone/pager
Occupation: ____________________________ Hobbies/Skills/Interests:
________________________________
Volunteer Opportunities
Directions: Please check all boxes that match your interests.
Interested: Volunteer Opportunity::
Baking
Chaperone (field trips)
Cleaning
Coaching/assistant coaching (check specific area of interest below)
( volleyball soccer basketball other: _______)
Committee Involvement (Check all that apply)
Budget & Finance (elected committee) Curriculum Review
CSI (School Improvement) Special Ed Advisory Extra Curricular
Facilities Online Steering Committee
Personnel (elected committee) Technology
School Board (elected committee) Steering (Elementary & Secondary)
Student Enrichment Transportation Wellness Committee
Concession Photography
Computer work Previewing Books/DVD
Construction Program Steering
Handiwork Review Curriculum
Library/Media Help Research
Lunch Room Assistant Room Parties
Nursery Help Sewing
Office Help Shopping/Errands
Other: ___________________ Skilled Labor (Describe: ___________________)
Painting TA (Classroom Volunteer)
Computer Graphics/publishing Word processing/data entry
Reminder: The success of PACT Charter School is directly related to the involvement of its
families. 4 volunteer hours is the minimum expectation monthly.
Criminal Background Check Informed-Consent Form for Volunteers: PACT Charter School Volunteer Program
requires volunteers to complete a Criminal Background Check Informed-Consent Form to protect our volunteers, staff and
students. The level of risk in a volunteer situation will determine whether a check will be done.
DCD (please fill out both sides, Thank you) 9/1/2011

TA Confidentiality Agreement
Directions: Please read and sign this document if you are in agreement with its contents. Return the completed form to the
Volunteer Coordinator, prior to volunteering as a teacher’s assistant (TA) in a classroom, for the school year.
I agree to abide by the PACT Mission Statement and the Teacher Assistant Handbook as presented to me as of this date.
I will, to the best of my ability:
Maintain confidentiality
Protect and promote student rights to:
dignity
privacy
respect
Demonstrate
honesty
loyalty
dependability
responsibility and accountability for my own actions
cooperation
a willingness to learn
I agree to hold all student information confidential, to be discussed ONLY with those directly responsible
for that student’s learning.
Signed: ___________________________________________
Date: ________________________________
PACT Charter School
“Mission Statement”
Partnering together as parents, students and teachers:
prepare students for college and life-long learning
promote positive character development
pursue a community atmosphere of mutual respect
DCD (please fill out both sides, Thank you) 9/1/2011

CHILD PROTECTION BACKGROUND CHECK
PACT CHARTER SCHOOL
7250 East Ramsey Parkway
Ramsey, MN 55303
T63574613
Because the position for which you are applying will require you to provide care, treatment, education, training,
instruction, or recreation to children, PACT Charter School will request the Bureau of Criminal Apprehension
(BCA) to perform a background check on you under Minnesota Statutes Chapter 299C.62, Section 20.
Have you ever been convicted of any of the following crimes? (If yes, please attach a description of the crime and
the particulars of the conviction.)
❑YES ❑NO
BACKGROUND CHECK CRIMES
Under Minnesota Statutes Chapter 229C
❑ Murder ❑ Felony Level Assault ❑ Kidnapping
❑ Criminal Sexual Conduct ❑ Manslaughter ❑ Arson
❑ Prostitution-Related Crime ❑ Any Assault Crime Against a Minor
❑ Any of the following Child Abuse Crimes committed against a Minor Victim,
constituting a violation of
Minnesota Statute Sections:
609.185, (5) Murder in the 1 st Degree
609.221 Assault in the 1 st Degree
609.222 Assault in the 2 nd Degree
609.223 Assault in the 3 rd Degree
609.224 Assault in the 5 th Degree
609.322 Solicitation, Inducement and Promotion of Prostitution
609.323 Receiving Profit Derived from Prostitution
609.324 Other Prohibited acts of Prostitution
609.342 Criminal Sexual Conduct in the 1 st Degree
609.343 Criminal Sexual Conduct in the 2 nd Degree
609.344 Criminal Sexual Conduct in the 3 rd Degree
609.345 Criminal Sexual Conduct in the 4 th Degree
609.352 Solicitation of Children to Engage in Sexual Conduct
609.377 Malicious Punishment of a Child
609.378 Neglect or Endangerment of a Child
152.021, subd.1, (4) Controlled Substance Crime in the 1 st Degree
152.022, subd.1, (5) Controlled Substance Crime in the 2 nd Degree
152.022, subd.1, (6) Controlled Substance Crime in the 2 nd Degree
DCD (please fill out both sides, Thank you) 9/1/2011

152.023, subd.1, (3) Controlled Substance Crime in the 3 rd Degree
152.023, subd.1, (4) Controlled Substance Crime in the 3 rd Degree
152.023, subd.2, (6) Controlled Substance Crime in the 3 rd Degree
152.023, subd.2, (7) Controlled Substance Crime in the 3 rd Degree
152.024, subd.1, (2) Controlled Substance Crime in the 4 th Degree
152.024, subd.1, (3) Controlled Substance Crime in the 4 th Degree
152.024, subd.1, (4) Controlled Substance Crime in the 4 th Degree
As the subject of a Volunteer background check, your rights include:
♦ To be informed that PACT will request this check for becoming or continuing as a volunteer, and to determine
whether you have been convicted of any of the above specified crimes, and
♦ To be informed of the BCA response and obtain a copy of the report from PACT
♦ To obtain from the BCA any record that forms the basis for the report, and
♦ To be informed whether PACT has denied your application because of the BCA response.
Minnesota statutes and the BCA require you to complete the following information in order to complete the background check:
PLEASE PRINT
_____________________________ _____________________________ _________________________________
Last name of Applicant First Name of Applicant Full Middle Name of Applicant
_______________________________________ _______________________ ___________________________
Maiden, Alias or Former Name Date of Birth Social Security Number (optional)
Sex: ❑ Male ❑ Female ______________________________________ _______________________
Signature
date
This release is valid for one year from the date of my signature
DCD (please fill out both sides, Thank you) 9/1/2011