Catholic Memorial High School

601 E College Ave

Waukesha, WI 53186-5538 CMH Volunteers
262-542-7101
Not submitting a social security number for a background
check may result in an inaccurate report
The Very Reverend Paul B.R. Hartmann, President
Robert Hall, Principal

PRINT CLEARLY

Name: Last First Neme Middle Name Social Security Number

(Necessary to insure an accurate report)

P
E
R Address Street City State Zip Code + 4 Birth Date
S
O
N Parish: Parish City: Telephone ( )
A
L Volunteer Area at CMH E-mail:

REFERENCES AND BACKGROUND INFORMATION

A
P CMH commits to providing a safe environment for all people using our premises and programs. This part of the form is to be
P completed by everyone who regularly volunteers for any position involving the care, supervision, or instruction of minors. It is a
L critical part of our school’s efforts to provide a safe and secure environment for children and young people in our school.
I
C Please provide the name and phone of two personal references:
A
Name ______________________________________________ Phone ___________________________________ Relationship ______________________
N
T Name ______________________________________________ Phone ___________________________________ Relationship ______________________

D _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
A
T Have you ever been convicted of, or pled guilty or nolo contendere to an offense (including felony, misdemeanor, or municipal
A ordinance) or are you now subject to a pending criminal charge? Yes No If yes, describe in detail.
(Convictions or pending charges will be considered in the process only to the extent they substantially relate
to the circumstances of volunteering sought by the applicant.)

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

BEFORE WORKING WITH STUDENTS AT CMH:

Complete this Volunteer Application Form, submit the signature page from Archdiocesan policy articles, and certify that
you have already completed a Safe Environment Education class; or if you have registered to take a class before working
with our students:

Location SEE class was taken __________________________________________ Date class was taken _________________

I have/will register to attend a Safe Environment Education class at ____________________________ on _______________

Equal Opportunity Employer

Page 1 of 3 →
 I hereby declare the information provided by me in this application is true, correct and complete to the best of my knowledge. I understand that
D if put to service, any misstatement or omission of fact on this application shall be considered cause for the discontinuation of volunteer duties.
E
C I understand that, consistent with State regulations, I may be required to submit to, or provide evidence of, tuberculin testing and/or chest X-
L rays, and be declared free of such disease by qualified medical personnel. I further consent to a drug screening at any time, if requested, during
A the course of my volunteer services.
R
A I understand that an investigation may be made of my application to arrive at a confirmation of accepting my volunteer services. I hereby
release from all liability or responsibility, all persons, schools, and/or companies furnishing such information. I understand that only volunteer-
T
related information will be used in the evaluation of my qualifications for any volunteer position for which I am considered.
I
O
N

Date: ____________________________ Signature: _____________________________________________________________________

July 2010

Documents submitted with this form become the property of the CMH Human Resources Department and will not be returned.

CRIMINAL RECORD CHECK CONTINGENCY

VOLUNTEERS

I understand that volunteering to work with CMH students is contingent upon the results of a criminal
records check performed for and approved by Catholic Memorial High School. Convictions or pending
charges will be considered only to the extent they substantially relate to the circumstances of volunteer
contact sought by the applicant.

I further understand that the criminal records check will be conducted and completed within two weeks of this
form being received in the CMH President's office.

____________________________________________________ ____________
Applicant name (please print) Date

__________________________ _____________________________________
Birth Date Social Security Number
(Necessary to insure an accurate report)

Applicant signature

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 ATTENTION ALL VOLUNTEER PARENTS, COACHES,
STAFF

THREE ARCHDIOCESAN/CMH REQUIREMENTS TO BE

COMPLETED
BEFORE WORKING WITH STUDENTS

1.) CMH APPLICATION FORM

Complete application form and contingency form (used to process criminal background check)
Request forms and return them to Katie Doyle at Catholic Memorial High School.
kdoyle@catholicmemorial.net

2.) SIGN UP FOR A SEE CLASS . . . If you have not taken a class before
www.archmil.org
First page, bottom right
Safeguarding All of God’s Family
Second page, bottom left
Upcoming Safe Environment Education (SEE) Sessions
View list of this month’s sessions
Register for a SEE class
Provide proof of SEE class attendance to CMH

3.) READ ARCHDIOCESAN POLICIES, return signature page to CMH

www.archmil.org
First page, bottom right
Safeguarding All of God’s Family
Second page, top right
Employees and Volunteers
READ: Mandatory Reporting Responsibilities
READ: Code of Ethical Standards, at bottom of article go to ---
o Details on Code of Ethical Standards, select English version
o Page 16 is the signature page, print that one page, sign and return it to me after you have read the policy.
\

Katie Doyle
CMH Safe Environment Education Coordinator
Administrative Assistant to the President
kdoyle@catholicmemorial.net
(262) 542-7101 ext. 246
Fax: (262) 521-4444
July 2010