The Dallas School District aims to ensure the safety of all it students.  It is for this reason that volunteers are asked to complete this application.  All information listed on this form is considered confidential.

  

SCHOOL VOLUNTEER PARENT APPLICATION

 

Please type or print your responses to all the following questions:

 

NAME                                                                                                                                      

 

ADDRESS                                                                                                                                

 

TELEPHONE                                           

 

NAME OF SCHOOL YOU WISH TO VOLUNTEER AT                                                               

Please complete a separate application for each school volunteer program participated in.

  

I, the undersigned, have read Policy 916, School Volunteers.

 

I, the undersigned, do hereby give the Dallas School District permission to release any and all information to the appropriate Law Enforcement Agency.

 

Your Signature                                                                         Date                                        

 

TUBERCULOSIS ASSESSMENT (To be completed by all Volunteers):

 

Please answer the following questions.  Have you had or do you have an of the following?

 

Night sweats                                                                 Productive cough               

Fatigue                                                                         Fever                                 

Weight loss                  

 

 

Any “YES” answers should be followed by your health care provider.

 

 

TUBERCULOSIS ASSESSMENT (To be completed by the School District Nurse or health care provider):

Tuberculin Tests Date Applied	Arm	Device	Antigen	Manufacturer	Signature
Date Read	Results (MM)		Signature