Volunteer Submission Form

Faulkton Area Schools Volunteer Submission Form

       In accordance with South Dakota State Law 13-10-12, the Faulkton Area Schools, in an attempt to protect students, requires volunteer coaches and other personnel to complete and sign the following.

Name _______________________________ Soc. Sec. Number ___________________

 Mailing Address _________________________________________________________

How long have you lived at this address?  __________________


List three persons not related to you who have knowledge of you and your background.


1.      Name ______________________________  Relationship __________________

Address: ____________________________________  Phone _______________


       2.  Name ______________________________   Relationship __________________

            Address: ____________________________________  Phone _______________


3.  Name ______________________________   Relationship __________________

     Address: ____________________________________  Phone _______________

       Have you ever been convicted of or pled “no contest” to or otherwise received a

       deferred sentence in consideration of fulfilling the terms of probation as to any

       felony or any crime relating to child abuse or neglect, any crime involving use or

       sale of any illegally controlled substances, or any crime relating to sexual abuse       

       of a minor?      _______ YES           _______ NO

       I further acknowledge that the Faulkton Area Schools may, at its discretion, make inquiries of law enforcement agencies and/or references for the purpose of verifying information.  This signed document is to be returned and filed in the office of the district superintendent.

       I affirm that information contained within is true.


_____________________________                                              ____________________

Volunteer’s Signature                                                                    Date