| IMPORTANT: Please note that this form may take up to 30 days to process, and plan accordingly. |
|
| Volunteer as:
| Please select as many options as apply. |
| |
|
|
|
|
|
|
| Gender:
|
|
| |
|
|
| Work Experience: Company Duties Years |
|
|
|
| Volunteer Category - I am a(n):
|
Please select YOUR age. |
|
Please provide 3 personal references:
Name Address Phone |
|
|
| Have you been fingerprinted within the past 5 years?:
| |
| |
|
|
| Have you ever been convicted of a felony?:
| |
|
|
|
| Have you ever served as a volunteer?:
| |
| |
|
|
|
|
Emergency and Health Information |
|
|
| Please list any health limitations:
|
|
|
| Note: School volunteers are covered for liability and injury while serving if they are appointed pursuant to s.228.041 and if there are records of service and job duties maintained by the district. The employee/volunteer information form must be completed. Volunteers are not considered wage earning and therefore cannot collect wage loss benefits. |
|
Confidentiality Statement
|
|
"I understand that in the course of my work in a school facility, I will be exposed to information that is confidential in nature. I will not discuss any of this information with anyone, including members of my own family." DeSoto County School District requests that any personnel with direct contact of students be fingerprinted. Typing your name below and submitting this form confirms your agreement to the Employee/Volunteer Information Form, the Confidentiality Statement, and fingerprinting requirement. |
|
|
State of Florida
Workers Compensation
Special Disability Fund 440.49 F.S.
Employee/Volunteer Information
Chapter 440, Florida Statutes provides for recovery from the Special Disability Trust Fund where an injury merges with a preexisting permanent physical impairment to cause greater disability than would have resulted from the injury alone. However, in order to recover from the Special Disability Trust Fund it is required that the State have knowledge of this impairment prior to the occurence of the compensable injury. In addition to a general category of impairments there are certain specific impairments outlined by the above statutes. Therefore, the following questions are to be answered by each employee and volunteer as defined in Section 110.501, F.S.
|
|
| 1. Have you ever had a serious illness, injury, or operation?:
| |
|
|
|
| If "Yes", please explain:
|
|
|
| 2. Have you ever received Worker's Compensation benefits for an injury?:
| |
|
|
|
| 3. Do you now have or have you ever had any disability rating, either temporary or permanent, assignment to you by an insurance company or governmental agency either Federal, State, County, or City? |
| |
|
|
| 4. Do you now have or have you ever had any physical handicap or disability including the following? If so, please select all that apply: |
|
|
| 5. Have you ever had or do you now have back trouble or complaints?:
| |
|
|
|
| 6. Have you ever had (please select all that apply): |
|
|
| Explain all items checked:
|
|
|
Thank you for volunteering!
. |
|
This box for Volunteer Coordinator use only!
|
| Volunteer Coordinator: before approving this form, please click the following box to indicate that an FDLE check has been completed. |
| |
|
|
|
