Dysart Volunteer Application
BEFORE COMPLETING THIS FORM, PLEASE REVIEW THE VOLUNTEER HANDBOOK.  Once you have completed your review of the Volunteer Handbook, please complete all questions and click submit!  Your results will be received and reviewed by the Volunteer and Compliance Specialist.  Once all information is validated, the Specialist will contact you to make an appointment for final steps in becoming an approved volunteer for the Dysart Unified School District.  Thank you in advance for your service to our students and school community!
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Email *
Last Name *
First Name *
Street Address *
City *
Zip Code *
Home Phone Number *
Cell Phone *
Emergency Contact #1:  Name,  Phone *
Emergency Contact #2:  Name, Phone *
Family Physician Name and Phone:
List any medical conditions or allergies, NA if none *
Have you previously volunteered at DUSD? *
Do you have a school preference?  (Select all that apply) *
Required
Please provide a brief description of the program, team, class, or activity, the direct supervisor in this area, and the work you've been asked to volunteer for: *
Will you be serving on a booster or parent group as a part of your volunteer work: *
Do you have a current Fingerprint Clearance Card *
HANDBOOK AND ORIENTATION AGREEMENT: By entering my name below I hereby attest that I have fully read and agree to all terms described in the Volunteer Handbook.  I understand that I cannot begin volunteering until I have met with and been fully cleared by the Dysart Unified School District Volunteer and Compliance Specialist, I certify the answers I've provided on this form are true, accurate and complete. I understand any misrepresentation of fact, false statements, or material omissions will result in the cancellation of my volunteer status with Dysart Unified School District. I also understand that district health insurance or workman’s compensation insurance will not cover any incidents that may occur while I am volunteering for the district. *
CONFIDENTIALITY AGREEMENT:  By entering my name below I agree, as a volunteer of Dysart Unified School District #89, have been informed of my personal responsibility to honor and protect confidential matters and documents to which I have been exposed or have access to in my official volunteer duties.Furthermore, I understand and agree that willful violation of the confidentiality of any student’s school related information shall result in immediate removal from my volunteer assignment.Volunteers are required to comply with all requirements concerning handling of and exposure to confidential in formation and materials in the school setting.   My name below attest to my agreement regarding the confidentiality requirement for volunteers. *
STATEMENT OF UNDERSTANDING:  Please read the following statement carefully and indicate your understanding and acceptance by entering your name below. My agreement below constitutes authorization to check my employment history, including without limitation,criminal arrest and conviction record checks, reference checks, and release of investigatory information possessed by any state, local or federal agency. I further authorize those persons, agencies or entities that the Dysart Unified School District #89 contacts in connection with my volunteer application to fully provide the Dysart Unified School District #89 with all information it requests.I hereby release the Dysart Unified School District #89, its members, employees and agents from any claims, including without limitation, defamation, emotional distress, invasion of privacy or interference with contractual relations that I might otherwise have against the Dysart Unified School District #89, its agents, officials, or against any provider of such information.I understand that information submitted in and with this application may be disclosed to a screening and/or interviewing committee, which may include Board Members, administrators, other staff and members of the community. I give my consent to this disclosure.I certify that I have read this form in its entirety and that the information herein provided is true, accurate and complete. I understand that, should any statement I have made prove to be false, or misleading, it may result in the rejection of my volunteer application or in my discharge if I am volunteering. If already volunteering, I also understand that any misstatement or omission of fact on this application may result in my discharge.I understand that all documents I provide to Dysart Unified School District #89 as part of my volunteer application will become property of Dysart Unified School District and will not be returned. Failure to disclose a criminal background may preclude you from volunteering with Dysart. Your fingerprints will be used to check the criminal history records of the FBI. If you have a criminal history record, you will be afforded 90 days to correct or complete the record before you will be denied the opportunity to volunteer.  To obtain a copy of your Arizona criminal history in order to review/update/correct the record, you can contact the Arizona Department of Public Safety Criminal History Records Unit at (602) 223-2222 to obtain a fingerprint card and a Review and Challenge packet. More information can be found at (azdps.gov). *
Privacy Act Statement:  Please read the following statement carefully and indicate your understanding and acceptance by entering your name below.  The FBI's acquisition, preservation, and exchange of fingerprints and associated information is generally authorized under 28 U.S.C. 534. Depending on the nature of your application, supplemental authorities include Federal statutes, State statutes pursuant to Pub.L.92-544, Presidential Executive Orders, and federal regulations. Providing your fingerprints and associated information is voluntary; however, failure to do so may affect completion or approval of your application. Certain determinations, such as employment, licensing, and security clearances, may be predicated on fingerprint-based background checks. Your fingerprints and associated information/biometrics may be provided to the employing, investigating, or otherwise responsible agency, and/or the FBI for the purpose of comparing your fingerprints to other fingerprints in the FBI's Next Generation Indentification (NGI) system or its its successor systems (including civil, criminal, and latent fingerprint repositories) or other available records of the employing, investigating, or otherwise responsible agency. The FBI may retain your fingerprints and associated information/biometrics in NGI after the completion of the application and, while retained, your fingerprints may continue to be compared against other fingerprints submitted to or retained by NGI. During the processing of this application and for as long thereafter as your fingerprints and associated information/biometrics are retained in NGI, your information may be disclosed pursuant to your consent, and may be disclosed without your consent as permitted by the Privacy Act of 1974 and all applicable Routine Uses as my be published at any time in the Federal Register, including the Routine Uses for the NGI system and the FBI's Blanket Routine Uses. Routine uses included, but are not limited to, disclosures to: employing, governmental or authorized non-governmental agencies responsible for employment, contracting, licensing, security clearances, and other suitability determinations; local, state, tribal, or federal law enforcement agencies; criminal justice agencies; and agencies responsible for national security or public safety.  Information on how to review and challenge your FBI criminal history record can be found at www.fbi.gov  or by calling (304) 625-5590.
A copy of your responses will be emailed to the address you provided.
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