Please fully complete this form and return to Phyllis Hey, Partnership Developer at Lincoln Middle School OR mail directly to Portland Education Partnership, 196 Allen Ave., Portland, ME 04103

I. Volunteer Name
First Middle Initial Last
Address	Zip Code
Home Phone	Work Phone
Email Address	Your DOB
Student(s) name(s) please list all
Student(s) school(s) please list all ___________________________________________
Student(s) grade/teacher please list all
II. Current Employer
Employer Name
Address
Supervisor’s Name
III. References (three individuals who are not related to you).

Name ____________________________________ Daytime Phone ______________

Address _______________________________________Zip Code_________________

Email __________________________________________________________________

Name ____________________________________ Daytime Phone ______________

Address _______________________________________Zip Code_________________

Email __________________________________________________________________

Name ____________________________________ Daytime Phone ______________

Address _______________________________________Zip Code_________________

Email __________________________________________________________________

PLEASE COMPLETE BOTH SIDES.

IV. In case of an emergency, please notify:
Name			Phone
Physician’s Name			Phone
Significant Health Issue (optional)
Hospital Preference
V. Confidential Background Information
Have you ever been charged with, pleaded guilty or “no contest” (nolo contendere) or been convicted of any crime, other than a minor traffic offense?
	Yes ð	No ð
I understand that information submitted in and with this registration may be disclosed to Portland Partnership and Portland Public Schools administrators and staff. School staff may conduct a public records check. I give my consent to this disclosure.
Signature___________________________________________				Date______________

Office Use Only

Level of screening

Date background check complete