DATE:  _______________________

VOLUNTEER INFORMATION
				
Name		Home Phone		
Address		City, State, Zip		
Email				

EMERGENCY CONTACT INFORMATION

Name		Relationship		
Address		City, State, Zip		
Home Phone		Work Phone		

PERSONAL DATA

Please list all children currently enrolled in the school district:
Name	Grade	School	Name 	Grade 	School	
1.			4.			
2.			5.			
3.			6.			

Have you ever been convicted of a felony or misdemeanor?	   YES	   NO
If yes, explain (date, location, nature of this act) on a separate sheet of paper.

I wish to volunteer in the following schools:  (check all that apply)
 
  Elementary		   High			

I prefer to work ONLY in my child’s classroom:     	   YES      NO     	Teacher Name: 		
I prefer my child’s classroom, but would also consider other volunteer opportunities:  	   YES       NO	
Please describe:  		

Would you be interested in volunteering for one of the media centers?	   YES        NO     	
Please list days and times you are available for this school year:  		

Please list any other interests or skills you may have to contribute to our classrooms:		

REFERENCES

In order to process your application, four references must be provided in the spaces below.  References should include current or former employers, persons for whom you have volunteered for, or character references.  Please include complete information, and note if you are related to a reference.  All references will be sent a “Volunteer Reference Form” which must be returned directly to the District by the individual listed as a reference.

	NAME		ADDRESS		RELATIONSHIP	
1.						
						
2.						
						
3.						
						
4.						
						
Please fill out form completely and return to:
Volunteer Program
Holley Central School District
3800 North Main Street
Holley, New York 14470

I would be interested in the following volunteer opportunities:  (check all that apply)

Assisting students with projects	Weekly	Monthly	Occasionally	
Checking homework				
Library / media assistance				
Classroom activities				
Making copies				
Preparing supplies for future projects				
Reading to children				
Listening to children read				
Assistance in science labs				
General office assistance				
Assistance in the computer labs				
Assistance in the testing center				
Assistance in the nurse’s office
Other: