Please read the attached Volunteer Handbook for all Volunteer requirements by the Benicia Unified School District, complete the Registration Card, attach a copy of your current driver’s license or valid state ID card with a clear picture and return to the school office. YEARLY clearance is required by the Benicia Unified School District.
NOTE: If you plan to drive on field trips or school activities, please attach proof of insurance showing a minimum of 100/300K liability coverage. PLEASE PRINT CLEARLY – ALL FIELDS REQUIRED FOR CLEARANCE! INCOMPLETE INFORMATION MAY DELAY PROCESSING.
Full Name Home Address Home Phone
Work Phone
Birth date
Last 4 digits of SS#
Children: Name
Grade
Site
Name
Grade
Site
Name
Grade
Site
Person to contact in case of emergency: Name Home Phone
CDL # or ID #: Insurance Co: Date of Last TB Test: Megan’s Law Cleared: Yes All information verified by:
Exp. Date: coverage Results: pos.
neg.
No on:
BENICIA UNIFIED SCHOOL DISTRICT TO: RE:
All BUSD Volunteers Workers’ Compensation Coverage
This is to advise you that BENICIA UNIFIED SCHOOL DISTRICT has adopted a Board Resolution to cover authorized volunteers for the purpose of Workers’ Compensation Benefits. Workers’ Compensation benefits will be provided in accordance with the California Labor Code for any injury or illness sustained while engaged in the services of BENICIA UNIFIED SCHOOL DISTRICT. Should you be injured while serving in this capacity, and therefore covered under our Workers’ Compensation Self-Funded Program, we need to advise you that you would not be eligible to file any civil claim, action, or proceeding. By signing this document, you acknowledge that Workers’ Compensation benefits will be the sole remedy and agree to waive any civil liability. Signature: Date:
RE:
Clear Tuberculosis (TB) Verification
The Benicia Unified School District requires that all employees and volunteers who are working directly with students must present a Verification of Clear Tuberculosis result which has been taken within the last four (4) years. Tuberculosis verifications are valid for four (4) years. Please submit a copy of your recent TB test result to your School when returning your completed Volunteer Registration Form.
RE:
School Activities / Field Trips Volunteer/Chaperone Assistance
Prior to assuming a volunteer position that involves the direct supervision of students in a district-sponsored student activity program, a volunteer shall either obtain both a DOJ and FBI criminal background check through the district or possess an Activity Supervisor Clearance Certificate issued by the CCTC. (Education Code 40924) If attending any School/District sponsored activity and/or field trip, where you will be responsible for the direct supervision of students, this includes the transportation of students in your private vehicle, the Teacher in charge or School will furnish you with the Department of Justice Fingerprint clearance form and instructions.
CDL # or ID #: Exp. Date: Insurance Co: coverage. Date of Last TB Test: Results: pos. neg. Megan's Law Cleared: Yes No. All information verified by: on:.
Date. Time Slot. Available (Y / N). A. Saturday June 23rd. 8:00A to 12 N. B. Saturday June 23rd. 12 N to 4 PM. C. Saturday June 23rd. 4 PM to 8 PM. D. Saturday ...
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This policy does not in any way affect the District's. ability or right to terminate its association with any volunteer for any reason with or without. cause. A volunteer is defined as a parent, community member or other adult who assists at a school
Dike Newell School (PreK-2) Phippsburg Elementary (PreK-5) Bath Middle School (6-8). Fisher Mitchell School (3-5) Woolwich (PreK-8) Morse High School ...
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Commission for a blue card on the volunteer's behalf. ... provided on the blue card application form. ... usual residence is more than 50kms from the business .... Current Credit Card or account card from a bank/building society/credit union (with ..
their identity and checking these against the details provided ... Step 1: check the volunteer has completed Part B ... If an identification document is in a former name, an .... Frequently Asked Questions available on the Commission's website at ...
... (section 23), and record the document number/s (if applicable). ... usual residence is more than 50kms from the business address or the .... 1800 113 611. Fax:.
not include championships). My cash or check for $100 per child is attached. Page 1 of 1. Volunteer Form.pdf. Volunteer Form.pdf. Open. Extract. Open with.
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... another state, the District of Columbia, the Commonwealth of Puerto Rico or a ... the Pennsylvania State Police, and the Federal Bureau of Investigation,.
Individuals may volunteer to participate in a street team, at a Come. and Be Counted site, or at the deployment ... Inc, and other local youth service providers works to promote the Youth Count in the community. and facilitate the quarterly event. Pa
development, mother-centered care and the yogic principles of self-less service ... Income Generating Group (WIGG), the Garden Program and relevant activities ... o Provide training and workshops on entrepreneurship, business management ...
Policy number: ... involving drug or alcohol (such as driving under the influence or driving while intoxicated) in the last seven years. ______ ______. 3. I have had no more than three moving violations or accidents in the last three years. ______ __
