Form Bul-4841.0 School Volunteer Application - Los Angeles Unified School District

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Attachment A
Los Angeles Unified School District
School Volunteer Application
PARENT ____
STUDENT*____
COMMUNITY____
D.O.V.E.S. ** ____
STAFF: _____
ORG. /PARTNERSHIP: ____________________
(At Child’s School)
(LAUSD K-12)
(other Adult)
(Age 55 +)
(LAUSD Employee’s)
(Other than LAUSD)
TO BE COMPLETED BY THE
TO BE COMPLETED BY LAUSD SCHOOL PERSONNEL OR PARTNERSHIP/ORGANIZATION:
PARENT COMMUNITY
Date application received by coordinator: Month ____________
Day ____________
Year______________________
SERVICES BRANCH:
New Volunteer: ______
Continuing Volunteer Previous School Name _________________________ Year:_______________
If volunteer is a LAUSD employee please submit (his/her) employee number: ___________________________________________
MAILING LIST (date)
Organization / Partnerships: ____________________________________________Number of Hrs. per week : ________________
School volunteer is assigned to: ______________________________
District/Division _____________________________
_
WELCOME LETTER AND
Date of skin test: Month _______Day _______Year_______ /
Date of X-Ray: Month ________ Day _______Year__________
ID SENT (date)
Volunteer's assignment: ______________________________________Classroom number_________________________________
Student name: ________________________________________________________________________________________________
(by)
Volunteer Coordinator: ________________________________________________________________________________________ _
Dear potential volunteer,
In order to complete your application, please submit this form with your completed TB results to your school. It is necessary to register all school volunteers with
the Parent Community Services Branch so they may be considered for coverage under LAUSD Workers’ Compensation Insurance policy in case of injury on
school premises.
Circle One:
Mr.
Mrs.
Miss
Ms.
Other: ___First Name: ____________________________ Last Name: ___________________________________
Address: _____________________________________________ City: ______________________ State: ______________ Zip: ______________________
Phone: (
) _________________________ Bus. Phone: (
) _________________________ Birth Date: ______________________________
In case of an EMERGENCY, please call: _____________________________________________ Phone: (
) ______________________________
Two references (No family members):
Name: _________________________________Address:_________________________________City:_______State:_______Ph: (
)________________
Name: _________________________________Address:_________________________________City:_______State:_______Ph: (
)________________
How were you recruited? Circle appropriate item: Newspaper
Radio
School
Flyers
TV
Web/Internet
Other ____________________
Education and Experience: _____________________________________________________________________________________________________
Degrees Achieved: ___________________________________________ Language(s) Spoken: ________________________________________________
Work Experiences: _____________________________________________________________________________________________________________
Employed? If so, employed at __________________________________________ Occupation: _______________________________________________
Volunteer experiences __________________________________________________________________________________________________________
Placement (Please Circle):
Where Needed
Near Home
I can serve: Morning___
Afternoon____
Evening ____
Days of Week I Can Serve:
Mon.
Tue.
Wed.
Thu.
Fri.
Sat. Max. # Of Hours per Day I Can Serve: ___________________________________
Volunteer Service (Circle all that apply): I can help with:
Reading
English
Math
Social Studies
Foreign Language Art
Library
Music
Science
Office Work
Computer
Other: _________________________________________________________________________
Grade level: Pre-School & K
Elem. (1-3)
Elem. (4-5)
Middle
Sr. High
Adults
Special Programs:
Adult Ed.
After-School
Children Center
Continuation
Special Ed.
SRLDP
ESL Health Services
Magnet Program
Other: ____________________________
School administrators must ensure that persons who volunteer for more than 16 hours per week or serve in an unsupervised capacity complete
fingerprinting by the DOJ and FBI prior to beginning assignments or work with students. Volunteers are eligible for service when the school receives a
copy of the Volunteer ID card and welcome letter from the Parent Community Services Branch.
The Board of Education of the City of Los Angeles and the California State Board of Education require that all school volunteers and employees be
tested for exposure to tuberculosis every four years. In accordance with Health and Safety Code §121545 volunteers must show proof of tuberculosis
clearance within six months prior to volunteering. The initial examination must consist of a Mantoux skin test. Volunteers may be tested by their own
physician or visit a Los Angeles County Health Center. K-12 LAUSD students are exempt from this TB test requirement.
I certify under penalty of perjury and in conformance with Education Code section §35021 that I am not required to register as a sex offender pursuant
to Penal Code section 290. I understand that, in accordance with District policy, school administrators will verify this information via the California
Megan’s Law database.
My Signature: __________________________________________________________ Date: _______________________________________________
Principal's signature:
School:
____________________________________________
_______________________________________________
*Parent's Signature (LAUSD K-12 Students Only): __________________________________________________________________________________
BUL-4841.0
Office of the Chief Academic Officer
Page 6 of 12
September 16, 2009

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