Volunteer & Instructor Application

Name_______________________________________ Email ____________________ Date _______________

Date of Birth Address_____________________________________

Two phone #s: _________________________________

I am a: Parent of Flagship student

(circle one) Community Volunteer

University student

How did you hear about the Flagship Program? ______________________________________________________

Related work and/or volunteer experience: __________________________________________________________

____________________________________________________________________________________________

Please list 2 work/volunteer references & 2 personal references

Name Address Phone # Relationship to you

_________________________________________________________________________________________

List schools you have attended, years in attendance, & degree(s) earned:

High school __________________________________________________________________________________

College______________________________________________________________________________________

If you plan to drive students during your time as an instructor/volunteer, please provide a copy of your driver’s license & insurance. In most cases, primary insurance coverage in the event of vehicle accident is with the vehicle transporting the student; therefore it is suggested that the transporting vehicle be insured for limits of at least $100,000 bodily injury liability per person, $300,000 bodily injury liability per accident, & $100,000 property damage.

Please fill out the following chart by checking all the times you could be available to instruct or volunteer:

8-9am 9-10am 10-11am 11a-12pm 12-1pm 1-2pm 2-3pm 3-4pm 4-5pm 5-6pm

Mon.
Tues.
Wed.
Thurs.
Fri.

Please list the activities and/or volunteer work you would like to be involved in, or programs you would like to run: _________________________________________________________________________________________

____________________________________________________________________________________________

Circle the age preference you would like to volunteer with or instruct:

Elementary Middle School High School

How long will you be able to instruct or volunteer?

______I agree that a limited records check through the Missoula County Sheriff’s Department or the Montana Identification Bureau files may be conducted on me to determine if any criminal convictions involving child abuse &/or child molestation have been proven against me. The purpose of such a check is to assist in providing a safe environment for the students involved in the Flagship Program.

_____I do not agree to a records check.

Have you ever been involved in, arrested for, or convicted of assault? _____________If yes, explain.

Have you ever been arrested for or convicted of child abuse, neglect, or child molestation? _______

If yes, explain.

Have you ever been arrested or convicted for a felony? ____________ If yes, explain.

If you will be driving students, please fill out the following information:

_______ I consent to a check of my Motor Vehicle Record with the Department of Motor Vehicles.

Please list any incidents on your driving record including, but not limited to speeding, accidents, etc._________________________________________________________________________________

If you will be driving students in a vehicle other than a Turning Point van or a University of Montana vehicle, please fill out the following information:

_______ I certify the vehicle is equipped with seat belts for all occupants.

_______ I certify the vehicle is regularly maintained & kept in good mechanical condition.

Confidentiality Statement

The Flagship Program follows the written policies of the Board of Trustees of Missoula County Public Schools & Turning Point Addiction Services regarding the knowledge & use of personal & academic student information. The Flagship Program is committed to ensuring the utmost confidentiality of all student information as acquired from students, teachers or the Flagship staff. Every student involved in Flagship has a right to privacy, & the Flagship Program staff & volunteers will uphold this right.

Information such as grades, class work or sensitive personal information revealed to you by the student, teachers, or the Flagship Program CANNOT be shared with friends or family. The name (whether first or last) or any identifying remarks about the student you are working with cannot be shared, referred to or hinted at.

By signing below, you agree that you will not share or discuss any personal or academic information about any student & you will uphold all students’ rights to privacy. By signing below, you are agreeing that if confidentiality is broken, the Flagship Program will take action & your position may be terminated.

I verify that the information provided on this form is true.

________________________________________________________________/____________________

Signature of volunteer or instructor Date