Joliet Township High School District 204	6:250-E
Instruction Exhibit – Volunteer Information Form and Waiver of Liability Only one form needs to be completed by a volunteer each school year. Please complete electronically or print clearly in ink and submit to the building principal:
Information Form
Name:	( ) -
Last	First	Middle	Phone
Address:
Street	City	Zip Code
Personal Physician:	Phone:	( ) -
Emergency Adult Contact:	Phone:	( ) -
Are you now or have you ever been a school volunteer?
At which school?	Year?
The name of any child or ward attending this school:
Criminal Conviction Information
Are you a child sex offender?
Have you ever been convicted of a felony?	If you answered YES, list all offenses.
Offense	Date	Place
If requested, are you willing to consent to a criminal background investigation?
Waiver of Liability
The school District does not provide liability insurance coverage to non-district personnel serving as volunteers for the School District. The purpose of this waiver is to provide notice to prospective volunteers that they do not have insurance coverage by the School District and to document the volunteer’s acknowledgment that they are providing volunteer service at their own risk.

By your signature below:
1.	You acknowledge that the School District does not provide insurance coverage for the volunteer for any loss, injuries, illness, or death resulting from the volunteer’s unpaid service to the School District.
2.	You agree to assume all risk for death or any loss, injury, illness or damage of any nature or kind, arising out of the volunteer’s supervised or unsupervised service to the School District, and agree to waive any and all claims against the School District, or its officers, board members, employees, agents or assigns, for loss due to death, injury, illness or damage of any kind arising out of the volunteer’s supervised or unsupervised service to the School District.
Date	Signature of Volunteer
Printed Name of Volunteer
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For School Use Only
General description of assignment(s):
Supervising students as needed by a teacher
Supervising students during a regularly scheduled activity
Assisting with academic programs
Assisting at the resource center or main office
Other	Joliet West Band Chaperone/Volunteer
Name of supervising staff member:	Eric Wellman
“Sex offender list” checked by	on	(mandatory)
Is a criminal background check necessary (the individual will be working over a long period of time in direct contact with students where no staff member is continuously present or in other situations where a check would be prudent)? (to be answered by Building Principal)
If “yes,” and provided that the individual authorized the check,
The date on which the check was requested?
The date on which it was received and reviewed?
Reviewed by:
Signature	Date
Date submitted: