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School District of Desoto
Volunteer Application
8/22/2019
IMPORTANT: Please note that this form may take up to 30 days to process, and plan accordingly.
Volunteer as:
Classroom Aide  Chaperone  
Office Aide  Other  
Please select as many options as apply.

If you selected "Other", please specify.

Personal Information

Name:
Last

First
Mailing address:
Street/P.O. Box

City

Zip Code
Phone Number:
Birthdate:
Gender:
Last Grade Completed:
Work Experience:          Company                          Duties                                                     Years
Present:


Previous:


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?:
Yes  No  

If you selected "Yes", which agency?
Have you ever been convicted of a felony?:
Yes  No  
Have you ever served as a volunteer?:
Yes  No  

If "Yes", where?

Times you can help:


Monday

Tuesday

Wednesday

Thursday

Friday

Emergency and Health Information

In case of any emergency, notify:
Name

Phone Number
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.
Volunteer's Name:


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?:
Yes  No  
If "Yes", please explain:
2. Have you ever received Worker's Compensation benefits for an injury?:
Yes  No  
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?
Yes  No  
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:
Epilepsy  Cerebral Palsy  
Hemophilia  Thrombophlebitis  
Cardiac Disease  Muscular Dystrophy  
Total Deafness  Multiple Sclerosis  
Diabetes  Vascular Disorder  
Hyperinsulinism  Chronic Osteomyelitis  
Parkinson's Disease  Mental Retardation  
Marie Strumpell Disease  
5. Have you ever had or do you now have back trouble or complaints?:
Yes  No  
6. Have you ever had (please select all that apply):
Amputation of foot, leg, arm, or hand  
Total loss of sight of one or both eyes or a partial loss of corrected vision of more than 75% bilaterally  
Herniated intervertebral disc  
Surgical removal of an intervertebral disc or spinal fusion  
Residual disability from poliomyelitis  
Psychoneurotic, emotional, or nervous disorder  
Ankylosis of a major weight-bearing joint  
Any permanent physical condition, which constitutes a 20% impairment of a member of the body as a whole  
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.

FDLE check completed  
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