Any person authorized by the district for volunteer service will be required to undergo an Oregon criminal records check.

* Required Fields

* First Name
Middle Name
* Last Name
* Date of Birth
* Gender

Driver License
Other Names Used
EMail Address
* Phone

* Address
* City
* State
* Zip

* Do you have students attending Bethel Schools?

* Where would you like to volunteer?

Bethel Farm
Cascade Middle School
Clear Lake Elementary
Danebo Elementary
Fairfield Elementary
Irving Elementary
Kalapuya High School
Malabon Elementary
Meadow View School
Prairie Mountain School
Shasta Middle School
Willamette High School
All District

* What type of volunteer work do you prefer?

What grade level would you prefer?


* Do you have any medical conditions we should know about in case of emergency?

If you have a medical condition, explain:

* Who should we contact in
case of emergency?

* Emergency Phone:

Physician's name:

Physician Phone:


* Have you ever volunteered at a school before?

Where and when did you volunteer?

* Questions A - H must be answered

If your answer is YES to any of the following questions, please give a detailed explanation in the space provided.

* A. Have you EVER been convicted of a sex-related crime?

If YES, what state? (If more than one state, please indicate other states in the Comment field below (for example: A - Minnesota)

If YES, did the crime involve force or minors?

* B. Have you EVER been convicted of a crime involving violence or threat of violence?

If YES, what state? (If more than one state, please indicate other states in the Comment field below (for example: B - Minnesota)

* C. Have you EVER been served a temporary or permanent stalking/restraining order?

* D. Have you EVER been arrested or cited for a crime involving criminal activity related to drugs or alcoholic beverages?

If YES, what state? (If more than one state, please indicate other states in the Comment field below (for example: D - Minnesota)

* E. Have you EVER been arrested of any other crime except a minor traffic violation? (Includes traffic crimes)

* F. Have you been arrested in the last three years for a crime for which there has not been an acquittal or dismissal?

* G. Have you ever entered into a diversion program for a misdemeanor or felony charge?

* H. Are you currently on parole or probation?

* I. Have you ever had civil judgments levied against you? (Do not include bankruptcy)

Please explain any "Yes" answers marked in questions A - I above and any multiple state arrests:

Read through the following School Board Policies then sign and submit the background check at the bottom of the page:

School Board Policy AC, Nondiscrimination

The District prohibits discrimination and harassment on any basis protected by law, including, but not limited to individual?s actual or perceived race, color, national or ethnic origin, cultural background, religion, veterans? status, genetic information, sex, gender, sexual orientation, marital status, age, mental or physical disability, pregnancy, socioeconomic status, source of income, familial status, physical characteristics, or linguistic characteristics of a national origin group or because of the perceived or actual protected status of any other person with whom the individual associates.

School Board Policy GBJ, Weapons in School - Staff & Volunteers

Employees, district contractors and/o their employees and district volunteers shall not possess a dangerous or deadly weapon or firearm on district property or at school-sponsored events. This prohibition includes those who may otherwise be permitted by law to carry such weapons.

School Board Policy JHFF, Reporting Requirements Regarding Sexual Conduct with Students

Sexual conduct by district/school employees or volunteers, as defined by Oregon law, will not be tolerated. Any district employee or volunteer who has reasonable cause to believe that another district employee or volunteer has engaged in sexual conduct with a student must immediately notify a district administrator or supervisor.

School Board Policy KGC, Tobacco Free Environment

Tobacco use, distribution, or sale by others on district property is also prohibited. Staff or others authorized to sue private vehicles to transport district students to school-sponsored activities are prohibited from using tobacco in those vehicles while students are under their care. This includes, but is not limited to lighted or unlighted cigarette, cigar, pipe, bidi, clove cigarette, and other smoking products, spit tobacco, nicotine or nicotine delivering devices, chemicals or devices that produce the physical effect of nicotine substances or any other tobacco substitute (e.g., e-cigarettes, vape pens, etc.).

Advisory: A check of the applicant's criminal history will be made by Bethel School District to verify the responses to the above questions.

I hereby grant Bethel School District permission to check civil or criminal records to verify any statement made on this form. Regardless of whether the applicant grants consent, Bethel School District will conduct a criminal offender record check of applicants for the position of school bus driver, volunteer or other prospective school employees working with or around children. The applicant is entitled to review his/her criminal history for inaccurate or incomplete information. Discrimination by an employer on the basis of arrest records also may violate federal civil rights law. The applicant may obtain further information concerning the applicants rights by contacting the Bureau of Labor and Industries, Civil Rights Division, State Office Building, Suite 1070, Portland OR 97232. Telephone 503-731-4075.

I acknowledge reading Bethel School Board Policies and the receipt of the above notice.

* Select "Signed" to digitally sign this document:


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