Su.125(1,01)

SAN BERNARDINO CITY UNIFIED SCHOOL DISTRICT SCHOOL VOLUNTEER APPLICATION (Please type or print)
SCHOOL	
Name 	
Last	First	Middle	Maiden Name / Other names used
Residence Address 	
Street	City	State	Zip
Home Telephone: 	Work Telephone: 
Emergency Contact Telephone: 	Message Phone:	
Birthday:                                                                                    Social Security Number:
Driver's License: Yes ( ) No ( )	State: 	License Number:	
Length Of Residence In San Bernardino: 	(Years)	(Months) 
Previous Address (If Less Than Five (5) Years) 	_
Physical Limitations: Yes ( )	No ( ) Explain _______	
Relationship To any Student(s) / Staff Member(s) At School: (Name)	

Languages Spoken: 	
Please respond to the following: "I am interested in volunteering because	
I CERTIFY THAT THE ABOVE RESPONSES ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. You Must List any Convictions For The Last Three (3) Years: Date:	 Charge:	
Date:	 Charge: 	 Date:	 Charge:	
Have you EVER been convicted of any sex offense for which you must register with any Law Enforcement Agency pursuant to Penal Code Section 290? Yes ( )	No ( )
I certify under Penalty of Perjury that the foregoing statements are true and complete, and I authorize the San Bernardino City Unified School District to complete a background check as a condition of school volunteer service, as provided by California Education Code § 45125.5
SIGNATURE 	DATE
 FORM MUST BE SENT TO SCHOOL POLICE WITHIN THREE (3) DAYS OF COMPLETION.