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VOLUNTEER APPLICANT DISCLOSURE STATEMENT PURSUANT TO CHAPTER 43.43 RCW

Please answer YES

or

NO

to each listed item. If the answer is

YES

to any item, explain in the area

provided, indicate the charge or finding, the date, and the court(s) involved. If you do not understand the

following questions or if you are uncertain as to your answer to those questions, do not complete this form

until such time as you are certain as to your response.

1. Have you

ever

been convicted of any crime? The term "

convicted"

means all adverse dispositions,

including a finding of guilty, a plea of guilty, a plea of guilty or nolo contendere, an

Alford plea,

stipulation to the facts, a deferred or suspended sentence, or a deferred prosecution.

_____

Yes _____ No. If yes, explain:

2. Have you

ever

had findings made against you in any civil adjudicative proceeding? "

Civil adjudicative

proceeding

" means any judicial or administrative adjudicative proceeding that results in a finding of, or

upholds an agency finding of, domestic violence, abuse, sexual abuse, neglect, or exploitation or

financial exploitation of a child or vulnerable adult under Chapters 13.34, 26.44, or 74.34 RCW, or rules

adopted under Chapters 18.51 and 74.42 RCW

. "Civil adjudicative proceeding"

also includes

judicial or administrative orders that become final due to the failure of the alleged perpetrator to timely

exercise a right afforded to him/her to administratively challenge findings made by the Department of

Social and Health Services or the Department of Health under Chapters 13.34, 26.44, or 74.34 RCW,

or rules adopted under Chapters 18.51 and 74.42 RCW.

_____ Yes _____ No. If yes, explain:

3. Have you

ever

been the subject of a complaint made to the Office of the Superintendent of Public

Instruction regarding whether you have committed an act of unprofessional conduct, as defined in WAC

181-187, or whether you are a person of good moral character and personal fitness as defined in WAC

181-79A-155?

_____ Yes _____ No. If yes, explain:

I agree that if I have provided false, misleading, or incomplete information, the District may, in its sole discretion,

disqualify me from volunteering or terminate my opportunity to volunteer with the District. I further agree that if at

any time in the future I am convicted of any crime, have findings made against me in a civil adjudicative

proceeding, or become the subject of a complaint made to the Office of the Superintendent of Public Instruction, I

will immediately notify the Everett Public Schools Volunteer Coordinator.

Pursuant to RCW 9A.72.085, I certify under penalty of perjury under the laws of the State of Washington that the

foregoing is true, correct, and complete. It is understood that this statement and record become the property of

the Everett School District. A criminal history check on volunteer applicants may be requested through the

Washington State Patrol or federal law enforcement agencies.

Print Name

City/State

Volunteer Signature

Date

THANK YOU FOR YOUR WILLINGNESS TO VOLUNTEER IN EVERETT PUBLIC SCHOOLS.

FOR LEGAL PURPOSES, THE INFORMATION WILL BE MAINTAINED BY THE DISTRICT.

Revised:

April 7, 1997

Revised:

July 2004

Revised:

February 2005

Proposed:

December 2008