ࡱ> ,.)*+{ 6 bjbjzz 7  t t 8T*@n;"]q @@@@@@@$BD7@}|;}}7@L@!!!}^@!}@!!]9T6:lUA^):?b@0@C:fE9 ffE4:fE:}}!}}}}}7@7@!^}}}@}}}}fE}}}}}}}}}t :   Section 1. Volunteer Applicant Information______________________________________________________________________________________________________________________Name______________________________________________________________________________________________________________________Street Address___________________________________________________________________________________________________ _________________CityStateZip________________________________________________________________________________________________________________Home TelephoneAlternate Telephone_____________________________________________________________________________________________________DATE OF BirthCA Drivers License No.Social Security No.Emergency ContactAddressPhone No. Section 2. Volunteer Job Description (to be completed by Supervising Administrator/Manager) _______________________________________________________________________________________________________________Job TitleLocation_______________________________________________________________________________________________________________________Department_____________________________________________________________________________________________________________Contact Person/SupervisorExt.Job Description:_____________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ Dates Needed:______________________________________________________________________________________ FromToTime RequiredMinimum Hours Per WeekTraining Required: FORMCHECKBOX Yes  FORMCHECKBOX No_______________________________________________________________________ By Whom______________________________________________________________________________________________________________________Qualifications_________________________________________________________________________________________________________________EducationSpecial Skills_____________________________________________________________________________________________________________ExperienceUse of AutomobileLicense Plate No______________________________________________________________________________________________________________________Other  Section 3. Report of Convictions No person may serve as a volunteer in the District if: He/she has been convicted of or if he/she has charges pending which pertains to any sex offense, such as child molestation (as defined in Education Code Section 87010), or controlled substance office (as defined in Education Code Section 87011).He/she has been convicted of a crime and a College President or District Administrator determines: the nature of the crime is too serious to serve as a volunteer; the crime was too recent; and/or the crime is inconsistent with obligations in performing assigned duties as a volunteer. He/she has a health condition which would preclude him/her form satisfactorily performing essential duties of the position.He/she makes a false statement or omits a statement as to any material fact on the application form. If you have a record of convictions for offenses other than minor traffic citations, please give details in the space below. Also, list any arrests for which you are currently out on bail or out on your recognizance, pending trial. If he answer is NONE, write it across the first line and sign your name at the end of the application. Convictions/Arrests Pending Trial: Date, City & State of ArrestCharge or reason given by police for arrestDate and location of trialExplanation (optional) Section 4. Additional Conditions for Serving as a Volunteer in the Peviogٷվ College District (1) Volunteer applicant acknowledges and understands that he/she serves the District in an at will capacity. The District may terminate a volunteers services for any reason at all, except for the exercising of free speech rights with respect to issues of public concern. (2) Volunteers are considered to be independent contractors and are employees of the District only for the purpose of entitlement to workers compensation benefits for injuries sustained while engaging in the performance of any services under the direction and control of the District . (3) With the exception of workers compensation and disability accommodation, volunteers serve without any type of compensation or benefits granted to District employees. Volunteers shall not be entitled to defense and indemnity from the District. (4) Individuals serving in Associated Student Organization officer positions at the colleges are not considered to be volunteers under the Districts volunteer policy and are not entitled to defense and indemnity from the District. (5) Volunteers are subject to Peviogٷվ College District Board Policies and Administrative Procedures I certify that the information I provided on this application form is true to the best of my knowledge and belief. I also accept the terms and conditions set forth by the District in connection with my volunteer service. Signature_________________________________________________________Date_________________________________ viogٷվ Form 7380 HR 12/12/12 st     Peviogٷվ College District Human Resources 333 East 8th Street Oakland, CA 94606 APPLICATION FOR VOLUNTEER SERVICES The information contained in this form shall be used in connection with all volunteer activities for the Peviogٷվ College District. INSTRUCTIONS Volunteer: Complete Sections 1, 3 and 4 and forward the form to the volunteer service area administrative supervisor. 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