- Office Use Only -
Springfield Public Schools
Criminal Record Check
Date: _____________
2009-2010
Volunteer Registration Form
School: ____________
Clear
& Request for Criminal Background Check
Provided Check
Record – Letter to Principal
SPS Employee
INSTRUCTIONS: (Please PRINT CLEARLY)
Complete this form (front & back) and mail or hand deliver to Volunteer Program, Kraft Administrative Center, 940 N Jefferson,
Springfield, MO 65802. You will be sent written notification upon approval of your background check which you may be
required to present at the school. (Please allow up to 14 business days)
This form must be completed each school year in order to keep your volunteer status current.
*DENOTES REQUIRED INFORMATION FOR PROCESSING PAPERWORK
*Date of Birth: (mm/dd/yyyy)
* Social Security #:
Gender:
Male
Female
*Last Name:
*First Name:
*M.I.
*Mailing Address:
*City/State:
Contact Phone #:
*Zip:
Email Address:
Have you previously completed a Volunteer Registration Form with Springfield Public Schools?
YES
NO If yes, what school year:
Are you currently employed by the Springfield Public Schools R-12 Have you ever been convicted of, or are you being
District?
YES
NO
charged with any felony?
YES
NO
What type(s) of volunteer service(s) do you want to provide?
Reading Tutor*
Math Tutor*
Classroom
Office
*Training is available upon request
Library
Field Trip
Other:
*At which SPS school(s) will you be volunteering?
Check Your primary affiliation to volunteering with the specified SPS site(s):
(1) Community Member (Adult)
(5) College:
(2) Parent -child’s name:
(6) RSVP
(3) PTA
(7) Faith Community:
(4) Grandparent -grandchild’s name:
(8) Business:
•
If Springfield Public Schools does not have a current background check on file for me, by signing below, I authorize them to
request my criminal background history and/or Child Abuse and Neglect (CAN) from the Missouri State Highway Patrol.
•
I will abide by Springfield Public Schools’ policies and guidelines.
•
Individuals with a felony charge will not be permitted to become a registered volunteer with SPS. Individuals with a
misdemeanor may be permitted to become a registered volunteer after approval by the Director of Community Relations. If
you have a child in SPS, this does not prevent you from being involved with your child during the school day.
This Criminal History Record Check document, signed by the applicant, will serve as written consent to check record information by the
requestor. The information obtained shall be confidential and any person who discloses the information beyond the scope allowed in
Section 43.540 shall be subject to prosecution for a Class A misdemeanor.
*Signature: _________________________________________ *Date: _______________________________
Revised 5/2009
Volunteer Protocol
Confidentiality/Ethics
Many of the policies that apply to employees of the School District are applicable to volunteers who are
participating in tutorial programs in classrooms. This section of Board adopted policy is abridged and lists
those sections that would also apply to volunteers.
The Board of Education expects that each employee shall put forth every effort to promote a quality instructional
program in the school district. The Board has stated its policies, rules and regulations in the manual entitled Board of
Education Policies and Regulations of the School District of Springfield R-XII. All employees are expected to be in
compliance with the contents of these policies, rules and regulations.
An effective education program requires employees with integrity, high ideals, empathy and human understanding. In
addition to these four essential characteristics, employees are expected to maintain high standards in their school
relationships. These standards include but are not limited to the following:
The employee shall:
A. Maintain just and courteous professional relationships with students, parents, staff members, and others.
B. Represent the school system in a positive manner on all public occasions.
C. Place the welfare of children as their first concern.
D. Refrain from using school contacts and privileges to promote partisan politics, sectarian religious views, or nonprofessional self-serving interests of any kind.
E. Properly use and protect all school properties, equipment, and materials.
F. Recognize basic dignities of all individuals with whom the employee interacts in the performance of duties.
G. In the performance of duties keep in confidence such information as the employee may secure, unless disclosure is
required by law.
H. A staff member should always take care not to imply through his or her individual actions an endorsement from
the district.
The Board expects employees to be familiar with the code of ethics that applies to them and to adhere to the code in their
relationships with students, parents, co-workers, and officials of the district.
Cross References:
BBFA, Board Member Conflict of Interest – Adopted: September 6, 2005
GBCA, Staff Conflict of Interest – Adopted: December 15, 1993
The School District of Springfield R-XII, Springfield, Missouri.
I have read the above information and agree to abide by Springfield Public Schools’ policies, rules and regulations.
Signature
Date