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

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