Questionnaire for Students Enrolled in Teacher Preparation Program

If you are in a teacher preparation program/planning to become a teacher or related service provider, please complete the following questionnaire.

As a volunteer working in the District of Columbia Public Schools, I agree to:

1. Sign in and out at the designated place during each visit.

DCPS tracks volunteer hours in each school. The efforts by individuals, volunteers and schools are recognized by DCPS as a quality service provided to students and staff.

2. Receive and wear a sticker provided from the front office to ensure school safety.

This will ensure that you are acknowledged as a contributing member of the school team during your volunteer time.

3. Attend any orientation or training session that may be necessary to help me in my job.

4. Honor the commitment to work as scheduled.

If you have a child in DCPS, please do not use your volunteer time to speak to your child's teacher or other staff members about your child. Schedule an appointment to address concerns related to your child.

5. Notify the DCPS representative assigned to work with me if I must be absent from a volunteer commitment.

6. Abide by all the school rules and DCPS policies and regulations that are applicable to me.

7. Maintain the confidentiality of any information I learn during volunteer work.

When you discuss students' needs with the teacher, you may learn some personal information. Such information must remain confidential and must not be discussed, except with appropriate staff members as needed.

Inform appropriate staff members, teachers, school counselor, and school principal if I suspect and/or learn that a child is in danger or exposed to any type of abuse or neglect.

Acknowledgment of Risks, Assumption of Risks, and Release/Waiver Agreement for DCPS Volunteer Activities

PLEASE READ THIS ENTIRE DOCUMENT CAREFULLY BEFORE SIGNING

I acknowledge and agree as follows:

1. That I must sign the District of Columbia Public School (DCPS) Acknowledgement of Risks, Assumption of Risks, and Release/Wavier Agreement before participating in the DCPS volunteer activity.

2. That if I am parent or legal guardian of a child under 18, I must sign a separate acknowledgement of Risks, Assumption of Risks, and Release/Wavier Agreement for the child before they can participate in the volunteer activity.

3. That some of the activities include risks that may cause or lead to injuries to volunteers. I understand that DCPS staff, employees or other personnel cannot assure a volunteer's safety or eliminate these risks. I am voluntarily participating with knowledge of the risks. Therefore, I assume and accept full responsibility for the risks of the activity (both known and unknown), and for any injury, damage, or other loss suffered by me, resulting from those risks.

4. That I will perform only those tasks assigned, observe all safety rules, and use care in the performance of my assignments.

5. That I will perform assigned tasks which are within my physical capability to the best of my ability, and that I will not undertake the tasks beyond my ability or physical capability.

6. That I am familiar with the safe operation and use of equipment and tools that I may utilize in connection with this volunteer activity, and that I will not undertake to use any equipment or tools with which I am unfamiliar or do not know how to operate safely.

7. That I am volunteering my service for this activity listed above on a voluntary basis without anticipation of payment or compensation of any kind.

8. That I agree to release and not to sue DCPS in regard to all claims, liabilities, suits, or expenses (hereafter collectively claim or claims), including claims caused or alleged to be caused by the negligence of DCPS, for any injury, damage or other loss to me in any way connected with my participation in this activity, or my use of DCPS equipment or facilities. I understand that I agree to waive all claims I may have against DCPS, and agree that neither I, nor anyone acting on my behalf, will make a claim or file a lawsuit against DCPS.

9. That I hereby agree to discharge, indemnify and hold harmless, all sponsors, and participating volunteer organizations, and their agents, employees and representatives, from all claims, demands, actions or judgments which I, or my heirs, executors, administrators or assigns may have for any and all injuries and damages, known or unknown, caused by or arising out of the activity listed above.

10. That I specifically acknowledge that I am engaging in the activity as a volunteer, at my own request and risk, and not as an employee of DCPS or their sponsors, and further acknowledge that I am not entitled to any compensation, benefit or insurance coverage from DCPS or their sponsors, nor will I make such claim.

11. That I have carefully read, understand and voluntarily sign this document and acknowledge that it shall be effective and binding upon me, my minor children and other family members, and my heirs, representatives and estate. Any option of this document deemed unlawful or unenforceable shall not affect the remaining provisions, and those remaining provisions shall continue in full force and effect.

Pursuant to the Criminal Background Checks For the Protection of Children Act of 2004 (D.C. Official Code § 4-1501.01 et seq.), this notice informs you that you have applied for, been appointed to, or you currently occupy, either as an employee or volunteer, a position that makes you subject to an initial criminal background check or traffic record check and to periodic record checks while assigned to the position. DCPS has been designated as a child or youth services provider agency that must conduct criminal background checks on its employees and volunteers. DCPS is authorized to conduct a criminal background check or traffic record check on you as an employee of or unsupervised volunteer with DCPS. DCPS must request certain information from you and provide you with notice and information on the requirement for the criminal background checks. DCPS uses two (2) forms to provide the required notice and information to you. This DCPS Individual Notification of Criminal Background Check and Traffic Record Checks Requirements Form is one of the forms. The second form is the DCPS Criminal Background Check Fingerprinting Affirmation, Authorization, and Disclosure Form. This form requests information from you about your history with law enforcement and requests your permission for DCPS to conduct a criminal background check on you. You will be asked to sign both forms.

I hereby acknowledge that I have received the DCPS Individual Notification of Criminal Background Check and Traffic Record Checks Requirements Form.

am applying to become a Volunteer for the District of Columbia Public Schools (DCPS) and that I do hereby authorize the release of any information to DCPS that they may request, from whomever they deem necessary to make such a request, from any of my police records, arrest records, and court records located at any jurisdiction in which I have lived and/or worked. I also release all persons from any liability that could result firm furnishing said information to DCPS. The original document is to be retained on file with DCPS. Any information obtained is subject to use by DCPS for educational related purpose.

Disclosure Statement

I declare or affirm under penalty of perjury that I have not been convicted of a crime, have not pleaded no contest am not on probation before judgment, do not have a placement of a case upon a stet docket, and have not been found guilty by reason of insanity for any sexual offenses or intra-family offenses in the District of Columbia or their equivalent in any other state or territory.

I also declare or affirm under penalty of perjury that I have not been convicted of and/or am not the subject of pending charges for the commission or attempt to commit any of the following offenses except as described below; murder; child abuse; rape; child pornography; kidnapping or abduction of a child; assault where the victim was a child under the age of sixteen years; illegal use, sale or distribution of controlled substance; illegal possession or use of any weapon. If you have been convicted and/or have pending charges for the offenses listed above please explain each below and attach a copy of the charging document and disposition, if applicable.

I further certify that I am the applicant whose signature is affixed below

When answering the following questions you may omit: (1) any violation of law committed before your 18th birthday, if finally decided in juvenile court; (2) any conviction, the record of which was expunged under federal, state, or local law.

YOU MUST LIST ALL OTHER CONVICTIONS FOR ANY CRIMINAL OFFENSES.

We will consider the date, facts, and circumstances of each event you list.

If “Yes” continue to Question 2. If “No” continue to Question 5.

2. Explanation of Convictions: Please give the following details for each conviction: (date of offense, charge(s) you were convicted of, place of violation, sentence/incarceration length, any additional information necessary):

Please read the listed offenses and then indicate the appropriate declarations in the next section.

1. Murder, attempted murder, manslaughter, or arson;
2. Assault, assault with a dangerous weapon, mayhem, malicious disfigurement, or threats to do bodily harm;
3. Burglary;
4. Robbery;
5. Kidnapping;
6. Illegal use or possession of a firearm;
7. Sexual offenses, including indecent exposure; promoting, procuring, compelling, soliciting, or engaging in prostitution; corrupting minors (sexual relations with children); molesting; voyeurism; committing sex acts in public; incest; rape; sexual assault; sexual battery; or sexual abuse; but excluding sodomy between consenting adults;
(8) Child abuse or cruelty to children; or
(9) Unlawful distribution of or possession with intent to distribute a controlled substance.