Temecula Preparatory School
Temecula Preparatory School A Heritage of Virtue, Wisdom and Knowledge
School Volunteer Application and Confidentiality Agreement (Please complete both pages) Name: (Last) _________________________________ (First) ___________________ (M.I.) ______ Date: ______________ Address: _________________________________________________________ Home Phone: __________________________ City/State: _________________________________ Zip Code: _______________ Cell Phone: __________________________ Email Address: _________________________________________________________________________________________ Full names & grades/teacher of children attending Temecula Preparatory School:
_______________________________
______________________________
_________________________
_______________________________
______________________________
_________________________
Duties/Position Desired: _________________________________________________________________________________ If you do not have a student at TPS, in what capacity would you like to volunteer? _______________________________ _____________________________________________________________________________________________ I understand that in the course of my volunteer duties at Temecula Preparatory School (TPS) I may have access to various types of confidential and restricted information. This information may be contained on a hard copy (paper), electronically (computer program or email), or verbally (via phone, face-to-face or overheard conversation). Restricted information includes, but is not limited to: A. Student and/or parent personal information such as: o social security number o addresses and phone numbers B. Student academic records such as: o grades o class schedules o academic transcripts and standings C. Employee information such as: o addresses o phone numbers I understand that I am offering to volunteer with Temecula Preparatory School and that TPS may, at its discretion, decline my offer of volunteer services. I understand that my volunteer services will require a Department of Justice criminal background check (Live Scan) as described in Education Code section 45125.1, and that I am responsible for the cost of the Live Scan and will not be reimbursed for this expense. **PLEASE NOTE** Not all reports of arrest, conviction or expungement will result in being denied volunteer clearance. Education Code sections 44830.1 and 45122.1 prohibit any person who has been convicted of a violent or serious felony from being employed by the School. An applicant for employment, contractor, or volunteer with a non-violent, non-serious criminal record will not automatically be disqualified.
35777 Abelia Street Winchester, CA 92596 www.temeculaprep.com (951) 926-6776
Temecula Preparatory School A Heritage of Virtue, Wisdom and Knowledge
PAGE 2 Further, if I am accepted as a volunteer: I agree not to access, review, disclose, copy, release, or use confidential student or staff information without specific authorization from a school administrator. I agree not to copy or use any confidential information for my own personal benefit. I understand that any breach of these confidentiality requirements will result in my immediate termination as a volunteer and may result in legal action against me. I also understand that even when I am no longer a volunteer with Temecula Preparatory School, any confidential information I have obtained must continue to be kept confidential. I understand that I must comply with all Temecula Preparatory School Board policies and school rules applicable to school staff as well as all directions from school administrators and staff while serving as a volunteer. I understand that my Volunteer Application must be approved through the Business Office prior to beginning any volunteering duties. I further understand that my authorization to serve as a volunteer may be terminated at the discretion of the Chief Executive Officer or designee at any time if they determine it is in the best interests of the school or the students. Any fraudulent application, violation of confidentiality, or any violation of the above provisions may result in termination of my status as a TPS volunteer, and may result in legal action against me. I, the undersigned, certify that the foregoing is true and correct. I acknowledge that I am volunteering without promise, expectation or receipt of compensation for my services. ______________________________________ ______________________________________ _______________________ Volunteer Signature Name Printed Date School Use Only DOJ Cleared □ Yes □ No
FBI Cleared □ Yes □ No
_____________________ SSN
_____________________________ ATI Number
_____________________________ SCN Number
____________________ __________________ ________________ Driver’s License TB Expire Date Date Badge Issued
_________________________ Term of Volunteer Duties Date
________________________ Date NLI Submitted to DOJ
_______________ By (name)
35777 Abelia Street Winchester, CA 92596 www.temeculaprep.com (951) 926-6776
________________ By (name)
State of California
Department of Justice
Clear
Print
REQUEST FOR LIVE SCAN SERVICE BCII 8016A (3/07)
Applicant Submission for Public Schools or Joint Powers Agencies ORI:
A3231 Code assigned by DOJ
Type of Applicant: (check one)
Classified School Emp.
Credentialed School Emp
The following selections are for Public Schools only: License, Certification, Permit
Peace Officer
Law Enforcement Personnel
Volunteer
Job Title or Type of License, Certification or Permit: Agency Address Set Contributing Agency:
07696
Temecula Preparatory School Agency authorized to receive criminal history information
Mail Code (five-digit code assigned by DOJ)
Teri Vernieri
35777 Abelia Street Street No.
Contact Name (Mandatory for all school submissions)
Street or P.O. Box
Winchester
CA
City
(951) 926-6776 x 6150
92596 Zip Code
State
Contact Telephone Number
Name of Applicant: (Please print)
Last
First
AKA's:
Middle Initial
CDL No. Last
First
DOB:
SEX:
HT:
WT:
Male
Female
Misc. No. BIL
Applicant to pay Agency Billing Number
EYE Color:
Misc. No.
HAIR Color:
Home Address:
(Applies only if Youth Org. / HRA or Public Utility submission)
POB: Street or P.O. Box
SOC: City, State and Zip Code
Your Number: OCA No. (Agency Identifying No.)
Level of Service:
✔
DOJ
✔ FBI
If resubmission, list Original ATI No. Live Scan Transaction Completed By:
Date: Name of Operator
Transmitting Agency
ATI Number
Amount Collected/Billed
ORIGINAL-Live Scan Operator; SECOND COPY - Applicant; THIRD COPY (if needed) - Requesting Agency
School Volunteer Application and Confidentiality Agreement (Please complete both pages) Name: (Last) _________________________________ (First) ___________________ (M.I.) ______ Date: ______________ Address: _________________________________________________________ Home Phone: __________________________ City/State: _________________________________ Zip Code: _______________ Cell Phone: __________________________ Email Address: _________________________________________________________________________________________ Full names & grades/teacher of children attending Temecula Preparatory School:
_______________________________
______________________________
_________________________
_______________________________
______________________________
_________________________
Duties/Position Desired: _________________________________________________________________________________ If you do not have a student at TPS, in what capacity would you like to volunteer? _______________________________ _____________________________________________________________________________________________ I understand that in the course of my volunteer duties at Temecula Preparatory School (TPS) I may have access to various types of confidential and restricted information. This information may be contained on a hard copy (paper), electronically (computer program or email), or verbally (via phone, face-to-face or overheard conversation). Restricted information includes, but is not limited to: A. Student and/or parent personal information such as: o social security number o addresses and phone numbers B. Student academic records such as: o grades o class schedules o academic transcripts and standings C. Employee information such as: o addresses o phone numbers I understand that I am offering to volunteer with Temecula Preparatory School and that TPS may, at its discretion, decline my offer of volunteer services. I understand that my volunteer services will require a Department of Justice criminal background check (Live Scan) as described in Education Code section 45125.1, and that I am responsible for the cost of the Live Scan and will not be reimbursed for this expense. **PLEASE NOTE** Not all reports of arrest, conviction or expungement will result in being denied volunteer clearance. Education Code sections 44830.1 and 45122.1 prohibit any person who has been convicted of a violent or serious felony from being employed by the School. An applicant for employment, contractor, or volunteer with a non-violent, non-serious criminal record will not automatically be disqualified.
35777 Abelia Street Winchester, CA 92596 www.temeculaprep.com (951) 926-6776
Temecula Preparatory School A Heritage of Virtue, Wisdom and Knowledge
PAGE 2 Further, if I am accepted as a volunteer: I agree not to access, review, disclose, copy, release, or use confidential student or staff information without specific authorization from a school administrator. I agree not to copy or use any confidential information for my own personal benefit. I understand that any breach of these confidentiality requirements will result in my immediate termination as a volunteer and may result in legal action against me. I also understand that even when I am no longer a volunteer with Temecula Preparatory School, any confidential information I have obtained must continue to be kept confidential. I understand that I must comply with all Temecula Preparatory School Board policies and school rules applicable to school staff as well as all directions from school administrators and staff while serving as a volunteer. I understand that my Volunteer Application must be approved through the Business Office prior to beginning any volunteering duties. I further understand that my authorization to serve as a volunteer may be terminated at the discretion of the Chief Executive Officer or designee at any time if they determine it is in the best interests of the school or the students. Any fraudulent application, violation of confidentiality, or any violation of the above provisions may result in termination of my status as a TPS volunteer, and may result in legal action against me. I, the undersigned, certify that the foregoing is true and correct. I acknowledge that I am volunteering without promise, expectation or receipt of compensation for my services. ______________________________________ ______________________________________ _______________________ Volunteer Signature Name Printed Date School Use Only DOJ Cleared □ Yes □ No
FBI Cleared □ Yes □ No
_____________________ SSN
_____________________________ ATI Number
_____________________________ SCN Number
____________________ __________________ ________________ Driver’s License TB Expire Date Date Badge Issued
_________________________ Term of Volunteer Duties Date
________________________ Date NLI Submitted to DOJ
_______________ By (name)
35777 Abelia Street Winchester, CA 92596 www.temeculaprep.com (951) 926-6776
________________ By (name)
State of California
Department of Justice
Clear
REQUEST FOR LIVE SCAN SERVICE BCII 8016A (3/07)
Applicant Submission for Public Schools or Joint Powers Agencies ORI:
A3231 Code assigned by DOJ
Type of Applicant: (check one)
Classified School Emp.
Credentialed School Emp
The following selections are for Public Schools only: License, Certification, Permit
Peace Officer
Law Enforcement Personnel
Volunteer
Job Title or Type of License, Certification or Permit: Agency Address Set Contributing Agency:
07696
Temecula Preparatory School Agency authorized to receive criminal history information
Mail Code (five-digit code assigned by DOJ)
Teri Vernieri
35777 Abelia Street Street No.
Contact Name (Mandatory for all school submissions)
Street or P.O. Box
Winchester
CA
City
(951) 926-6776 x 6150
92596 Zip Code
State
Contact Telephone Number
Name of Applicant: (Please print)
Last
First
AKA's:
Middle Initial
CDL No. Last
First
DOB:
SEX:
HT:
WT:
Male
Female
Misc. No. BIL
Applicant to pay Agency Billing Number
EYE Color:
Misc. No.
HAIR Color:
Home Address:
(Applies only if Youth Org. / HRA or Public Utility submission)
POB: Street or P.O. Box
SOC: City, State and Zip Code
Your Number: OCA No. (Agency Identifying No.)
Level of Service:
✔
DOJ
✔ FBI
If resubmission, list Original ATI No. Live Scan Transaction Completed By:
Date: Name of Operator
Transmitting Agency
ATI Number
Amount Collected/Billed
ORIGINAL-Live Scan Operator; SECOND COPY - Applicant; THIRD COPY (if needed) - Requesting Agency
