Volunteer Application Form 2017-18 BEAUMONT UNIFIED SCHOOL DISTRICT 350 BROOKSIDE AVENUE, PO BOX 187 - BEAUMONT, CA 92223 951-845-1631
Date: School Site: ____________________________________________ Teacher's Name:
Room #:
Student(s) Name(s): INSTRUCTIONS: Please fill out the front and back of this form completely if you are a new volunteer. If you are returning, current or an employee complete the front side only. Please print legibly in black or blue ink. Check mark the appropriate box on volunteer status. Sign the form at the bottom and on the back, if applicable. This application and any attachments become the property of the Beaumont Unified School District. NEW VOLUNTEER
RETURNING VOLUNTEER-WITHIN THE LAST TWO YEARS
CURRENT BUSD EMPLOYEE
Name:
CURRENT VOLUNTEER AT ANOTHER SITE
Phone #: Last
First
Middle
Address: Number & Street
City
Zip Code
Email : ___________________________________ List activities in which you would like to assist in: List proposed frequency of volunteering:
Seasonal Help Only
Field Trips
One time special event only
1 or more times a week
NOTE: All volunteers will be required to sign a loyalty oath, produce evidence that they are free of active tuberculosis and pass a DOJ background clearance. Please describe any physical condition or disability which may limit your ability to perform any of the duties of the volunteer service for which you are applying for and what reasonable accommodations need to be made:
Have you ever been convicted of a felony or misdemeanor ? Yes _____
No _____.
If you answered yes to the preceding question, please state and explain, in detail, each conviction on a separate sheet of paper and attach to this form. ( A conviction will not constitute an automatic bar from selection as a volunteer). I HEREBY CERTIFY that all statements made hereon are true and correct and authorize investigation of all statements herein recorded. I release from all liability persons and organizations reporting information required by this application.
Signature of Applicant
Date
FOR OFFICE USE ONLY
Volunteers shall not be used to displace regularly authorized school personnel (Education Code 35021). Projects assigned to volunteers are those which supplement and enrich the regular school program and which would not be offered without volunteer assistance. Volunteers shall work under the immediate supervision of a regular District employee.
Teacher/Supervisor:
Date:
Approved: ___ Yes
___ No
Principal/Administrator:
Date:
Approved: ___ Yes
___ No
Asst. Supt. of Human Resources:
Date:
Approved: ___ Yes
___ No
THIS SECTION FOR TRACKING PURPOSES ONLY TB voucher given/sent:
F/P Appt:
Entered into database:
TB results received:
F/P:
Copy sent to site:
TB results expire:
ML Search REV: 3/15
Forma de Aplicacion de Voluntario 2017-18 DISTRITO ESCOLAR DE BEAUMONT 350 BROOKSIDE AVENUE, PO BOX 187 - BEAUMONT, CA 92223 951-845-1631
Date: Sitio Escolar: ____________________________________________ Nombre de Maestro/a:
Salon #:
Nombre de Estudiante(s): INSTRUCCIONES Por favor llene la forma completamente de frente y detras si es voluntario nuevo. Si esta regresando, actual o empleado complete solo la parte de frente . Por favor escriba legible en negro o azul. Marque la caja apropriada en el estatus de voluntario. Firme la forma debajo y por atras, si aplica. Esta aplicacion y cualquier forma adjunta son propiedad del Distrito Escolar de Beaumont . NEW VOLUNTEER
RETURNING VOLUNTEER-WITHIN THE LAST TWO YEARS
CURRENT BUSD EMPLOYEE
Nombre:
CURRENT VOLUNTEER AT ANOTHER SITE
Tel #: Apellido
Nombre
Domicilio: Numero & Calle
Ciudad
Codigo postal
Email : ___________________________________ Aliste actividades en cual quiere ayudar: Lista de frequencia de voluntariado:
Seasonal Help Only
One time special event only
Field Trips
1 or more times a week
NOTA: Todo voluntario sera requerido firmar una declaracion de lealtad, producir evidencia de estar libre tuberculosis y pasar una certificacion de antecedentes DOJ. Por favor describa cualquier condicion fisica o discapacidad que pueda limitar su habilidad de hacer los deberes de servicio devoluntario por cual esta aplicando y que adaptaciones razonables necesitan hacerse:
Ha sido condenado de un delito o ofensa ? Si _____
No _____.
Si contesto si a la pregunta precedente, por favor declare y explique, en detalle, cada condena en una pagina de papel separada y adjunte a esta forma. (Una condena no constituye una prohibicion automatica de seleccion como voluntario). YO CERTIFICO POR LO PRESENTE que todas las declaraciones hechas son actuales y correctas y autorizo una investigacion de todas las declaraciones grabadas aqui. Dejo libre de toda culpabilidad personas y organizaciones reportando informacion requirida por esta aplicacion.
Firma del Solicitante
Fecha
PARA USO DEL PERSONAL DE OFICINA SOLAMENTE
Volunteers shall not be used to displace regularly authorized school personnel (Education Code 35021). Projects assigned to volunteers are those which supplement and enrich the regular school program and which would not be offered without volunteer assistance. Volunteers shall work under the immediate supervision of a regular District employee.
Teacher/Supervisor:
Date:
Approved: ___ Yes
___ No
Principal/Administrator:
Date:
Approved: ___ Yes
___ No
Asst. Supt. of Human Resources:
Date:
Approved: ___ Yes
___ No
ESTA SECCION PARA PROPOSITO DE ANOTACION DE RESULTADOS SOLAMENTE TB voucher given/sent:
F/P Appt:
Entered into database:
TB results received:
F/P:
Copy sent to site:
TB results expire:
ML Search REV: 3/15
OATH OF ALLEGIANCE
For Public Employees & Civil Defense Workers (Article XX, Const. Of California) } }
State of California County of Riverside
ss.
I do solemnly swear (or affirm) that I will support and defend the Constitution of the United States and the Constitution of the State of California against all enemies, foreign and domestic; that I will bear true faith and allegiance to the Constitution of the United States and the Constitution of the State of California; that I take this obligation freely, without any mental reservation or purpose of evasion; and that I will well and faithfully discharge the duties upon which I am about to enter. Signature:
Signed on this date of:
BEAUMONT UNIFIED SCHOOL DISTRICT
School District:
REQUEST FOR LIVE SCAN SERVICE Applicant Submission for Public School or Joint Powers Agencies
A5039
ORI :
The following selections are for Public Schools only: Type of Application: Volunteer Classified School Emp Credentialed School Emp
Code assigned by DOJ
Agency Address Set Contributing Agency: BEAUMONT UNIFIED SCHOOL DISTRICT
03553
Agency authorized to receive criminal history information
Mail Code (5 digit code assigned by DOJ)
Carol Araujo
350 BROOKSIDE AVE Street # or PO Box
Bill to:
Contact Name
BEAUMONT
CA
City
State
951-845-1631
92223
Zip Code
BEAUMONT UNIFIED SCHOOL DISTRICT
Contact Telephone No:
Level of Service:
FBI
DOJ
TO BE FILLED OUT BY APPLICANT SEX:
DOB:
Male
CDL #:
Height:
Female
Weight:
Eye Color: Name:
Hair Color: AKA'S:
Last
First
Middle
Last
First
Middle
Address: Street & Number
Place of Birth (city):
City
Zip Code
Social Security #: TO BE COMPLETED BY LIVE SCAN OPERATOR ONLY
Live Scan Transaction Completed by:
Name of Operator (PLEASE PRINT)
Live Scan Operator Signature: Transmitting Agency: ATI #:
BEAUMONT UNIFIED SCHOOL DISTRICT Date:
JURAMENTO DE FIDELIDAD
Para Empleados Públicos & Trabajadores de Defensa Civil (Artículo XX, Const. de California) } }
Estado de California Condado de Riverside
ss.
Yo solemnamente juro (o afirmo) que apoyare y defendere la Constitución de los Estados Unidos y la Constitución del Estado de California contra todo enemigo, extranjero y domestico; que yo tendré fe verdadera y alianza a la Constitución de los Estados Unidos y la Constitución del Estado de California; que tomare esta obligación libremente, sin reserva mental o propósito de evasión; y que desempeñare bien y fielmente los deberes en que voy a entrar. Firma:
Firmada en esta fecha:
BEAUMONT UNIFIED SCHOOL DISTRICT
Distrito Escolar:
REQUEST FOR LIVE SCAN SERVICE Applicant Submission for Public School or Joint Powers Agencies
A5039
ORI :
The following selections are for Public Schools only: Type of Application: Volunteer Classified School Emp Credentialed School Emp
Code assigned by DOJ
Agency Address Set Contributing Agency: BEAUMONT UNIFIED SCHOOL DISTRICT
03553
Agency authorized to receive criminal history information
Mail Code (5 digit code assigned by DOJ)
Carol Araujo
350 BROOKSIDE AVE Street # or PO Box
Bill to:
Contact Name
BEAUMONT
CA
City
State
951-845-1631
92223
Zip Code
BEAUMONT UNIFIED SCHOOL DISTRICT
Contact Telephone No:
Level of Service:
FBI
DOJ
PARA SER LLENADO POR SOLICITANTE GENERO:
FECHA NACIMIENTO:
Male
CDL #:
Estatura:
Female
Peso:
Color de ojos: Nombre:
Color de pelo: Alias'S:
Apellido
Nombre
Apeliido
Nombre
Domicilio: Numero y calle
Lugar de nacimiento (ciudad):
Ciudad
Codigo Postal
Seguro Social #:
TO BE COMPLETED BY LIVE SCAN OPERATOR ONLY Live Scan Transaction Completed by:
Name of Operator (PLEASE PRINT)
Live Scan Operator Signature: Transmitting Agency: ATI #:
BEAUMONT UNIFIED SCHOOL DISTRICT Date:
VOLUNTEER INFORMATION SHEET Complete the front and back of the Volunteer application if you are a new volunteer. If you are returning volunteer, current volunteer, or BUSD employee complete the front only. A new application must be completed every school year for every volunteer and for every school. Check mark the appropriate box above your name regarding your volunteer status. Obtain the signature of the teacher whose classroom you plan on volunteering in. Give the application to the secretary or volunteer representative at the school. They will obtain the signature of the principal. Once the signature has been obtained, they will call you and instruct you to pick up your application. If you are a returning volunteer, current volunteer, or BUSD employee, they will forward the application to the District Office for processing. If you are a new volunteer, once you receive your application contact the District receptionist at 845-1631 x5318 to pick up authorization forms to get your fingerprints taken. You need to bring your signed application and state issued photo ID to your fingerprint appointment. The fingerprints are taken on designated days at the Beaumont Police Department. You will be given a TB Voucher by the Receptionist at the District Office when you pick up paperwork for fingerprinting. You may submit a negative TB test with your application, but it may be no more than 60 days old. If you are currently employed by another school district, you may submit a negative TB test as long as it has been done within the last four years. This is per our Board Policy/Administrative Regulation 1240. Once you have been approved by the Assistant Superintendent of Human Resources, the school site will be notified. Please be advised that you are not approved to be on site as a volunteer until you receive the notification from the site. Please allow ten business days for processing. Thank you for volunteering with our School District. We value your time and contribution to our children’s educational experience.
HR/Volunteers/Volunteer checklist Revised July 7, 2015
Hoja de Información de Voluntarios Complete la frente y parte de atrás de la aplicación para voluntario. Si usted es un voluntario que este regresando, un voluntario actual o un empleado del distrito solo completen la frente. Una nueva aplicación debe ser completada todos los años para todos los voluntarios y para todas las escuelas. Marque la caja apropiada que se encuentra arriba de su nombre para decirnos su estatus de voluntario. Obtenga la firma de la maestra del salón en que planea ser voluntario. Entregue la aplicación a la secretaria o el representante de voluntarios de la escuela. Ellos obtendrán la firma de la directora. Ya que tengan la firma lo llamaran y le dirán que recoja la aplicación. Si usted es un voluntario que está regresando, un voluntario actual o un empleado del distrito ellos mandaran su aplicación a la oficina del distrito para procesarla. Si usted es un voluntario nuevo, ya que reciba su aplicación llame a la recepcionista del Distrito al 951-845-1631 x5318 para recoger autorización para huellas digitales. Cuando vaya por la autorización, lleve con usted la aplicación. Necesitara una identificación del estado. Las huellas digitales solo se hacen en ciertos horarios en el Departamento de Policía de Beaumont, localizado al 550 E. 6th Street. La recepcionista de la Oficina del Distrito le dará un cupon para que se haga una prueba de Tuberculosis. Puede entregar una prueba negativa de Tuberculosis con su aplicación pero no puede ser más de 60 días que lo haya tomado. Si usted es empleado de otro distrito puede entregar una prueba negativa de Tuberculosis si lo ha hecho durante 4 años. Por la póliza del Distrito y la Regulación Administrativa 1240 pedimos esta información. Ya que sea aprobado por el Asistente de Superintendente se notificara a la escuela. Favor de saber que no está aprobado para estar en la escuela como voluntario hasta que reciba notificación de parte de la escuela. Favor de permitir 10 días de trabajo para procesar.
¡Gracias por ser voluntario en nuestro Distrito! Valoramos su tiempo y contribución a la experiencia educativa de los niños. HR/Volunteers/Volunteer checklist Revised July 7, 2015
