Policy Details

1212 FORM School Volunteers FORM and Waiver of Liability

# 1212(a)

Form

LITCHFIELD PUBLIC SCHOOLS

Litchfield, Connecticut

Volunteer Information Form and Waiver of Liability

Only one form needs to be completed by a volunteer each school year. Please print clearly in ink:

Information Form

Name:__________________________ __________________________ ___________________

Last First Middle

Address:__________________________ _______________________ ____________________

Street City Zip Code

Telephone: ___________________________

Personal physician: __________________________________ Phone _______________________

Emergency adult contact: ______________________________ Phone _______________________

Are you now or have you ever been a school volunteer? _________________

At which school? ________________________________________ Year? __________________

The name of any child or ward attending this school:_______________________________________

Name of current year supervising staff member: ______________________________________

Criminal Conviction Information

Are you a sex offender? __________ Have you ever been convicted of a felony? __________

If you answered YES, list all offenses

Offense(s):____________________________________________________________________

Date(s):_______________________________________________________________________

Place(s):______________________________________________________________________

Waiver of Liability

The School District does not provide liability insurance coverage to non‑district personnel serving as volunteers for the School District. The purpose of this waiver is to provide notice to prospective volunteers that they do not have insurance coverage by the School District and to document the volunteer's acknowledgment that they are providing volunteer service at their own risk. However, C.G.S. 10-235 provides that the district must indemnify and hold harmless volunteers from civil liability in most situations as long as the volunteer is approved by the Board of Education to carry out a duty prescribed by the Board and performs services under the direction of a certified teacher. Therefore the district must pay any damages awarded to a plaintiff in an action brought alleging negligence or other act resulting in injury, including infringement of that person's civil rights.

By your signature below:

1. You acknowledge that the School District does not provide insurance coverage for the volunteer for any loss, injuries, illness, or death resulting from the volunteer's unpaid service to the School District.

2. You agree to assume all risk for death or any loss, injury, illness or damage of any nature or kind, arising out of the volunteer's supervised or unsupervised service to the School District, agree to waive any and all claims against the School District, or its officers, Board Members, employees, agents or assigns, for loss due to death, injury, illness or damage of any kind arising out of the volunteer's supervised or unsupervised service to the School District.

Date: __________________ Signature of Volunteer:_____________________________________

Printed Name of Volunteer_________________________________

******************************************************************************

For School Use Only

General description of assignment(s):

assisting students as needed by a teacher

assisting students during a regularly scheduled activity

assisting with academic programs

assisting at the resource center or main office

other ______________________________________________________________

Sex offender list" checked by ___________________ on _________________ (mandatory).

Fingerprinting Requested: _____ Yes _____ No

Principals Approval: ____________________________________________________________

Signature Date

Litchfield Board of Education

Form Adopted: 5/4/2011

Form Updated: 1/2015; 1/2016

Download a PDF of this Form and Waiver of Liability

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