Application for Volunteers


1. Please fill out this form completely.
2. Type or print in ink.
3. Sign the form at the bottom. 


This application and any attachments become the property of JCS, Inc. Deliver all completed application materials to JCS, Inc., P.O. Box 2470. Julian, CA 92036 


Name (Last, First, Middle)
	

	Phone
	

	

	Email
	

	Address
	

	

	

	Date of Birth
	

	

	CA Driver's License
	

	List Volunteer Experiences
	

	

	

	Name/Location of Current Employer
	

	

	

	List references other than family members:
	

	

	

	

	

	

NOTE 
1. Individuals who regularly perform one or more hours per week of any specific volunteer service with or around students shall be required to produce a copy of a negative Tuberculosis test taken within the last six (six) months indicating you are free of active tuberculosis. 
2. Additionally, all volunteers must follow student confidentiality requirements as defined by the Family Education Rights and Privacy Act of 1974 (FERPA). 




see other side
________________
Are you physically able to perform the functions of this position with/without accommodation?      Yes          No


Have you ever been convicted of a felony or misdemeanor, or do you currently have a felony or misdemeanor charge pending? Convictions include a plea of guilty, nolo contendere (no contest) and/or a finding of a guilty by a judge or a jury. (Exclude convictions for marijuana-related offenses for more than two years old.)     Yes          No


If “Yes”, list all convictions including, but not limited to convictions for “driving” under the influence,” and convictions for sex and/or drug offenses listed in California Education Code Sections 44010 and 44011, except for convictions related to marijuana if it is more than two years after the date of the conviction. Including any serious or violent felony conviction in any state or jurisdiction as enumerated in California Penal Code Sections 667.6© and 1192.7©. (Use a separate sheet of paper to explain details – 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. 


I AFFIRM that I have read and understand all of the attached annual notifications and requirements for JCS-Inc. unpaid volunteers. 




Signature of Applicant_____________________________________________                Date______________________ 


School Site        ___________________________________________________


Student Name         ___________________________________________________


Site Coordinator        ____________________________________________


Approved By         ___________________________________________________
(Principal/Designee)


2005.3 JCS, Inc. Volunteer Application                                                                Page  of 2