School:_______________________________Position:__________________
Check one:
_______Teacher with
initial certification
_______Teacher with 27
or more years of experience
Check all that apply:
_____ I am voluntarily requesting an extra-curricular assignment as_______________
at_________________School.
_____ I voluntarily agree to accept an assignment to an extra-curricular duty as
determined by the school principal based on the operational needs of the school program.
_____ I voluntarily agree to accept temporary assignments to extra-curricular duties
where deemed necessary by the school principal.
I understand that by accepting or requesting this extra-curricular assignment, I agree to perform all the duties required by this assignment for the duration of the assignment.
____________________________ ___________________________
(Teacher’s signature) (Principal’s signature)
____________________________ ___________________________
(Date signed) (Date
signed)
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