MIRACOSTA COMMUNITY COLLEGE DISTRICT
REQUEST / RECOMMENDATION FOR VOLUNTEER SERVICE
VOLUNTEER – Form RM–A — Request / Recommendation for Volunteer Service (03/2019)
Section C – Completed by Volunteer
This is to acknowledge receipt of information regarding California Workers’ Compensation laws
and rights, in
addition to notice regarding the Medical Provider Network that my employer/volunteer service provider utilizes.
I have read the “Employee Notice Workers' Compensation Benefits" doc
ument (see MCC Volunteer website) and
understand my rights and benefits under the Workers’ Compensation program. I agree to report all work-related
injuries and illnesses to my supervisor / employer / volunteer service provider immediately after they occur.
DATE
Section D – Completed by Parent / Guardian – ( IF THE VOLUNTEER IS A MINOR )
I have read and understand the above conditions and consent to the above-named individual’s participation as a
volunteer / unpaid employee of MiraCosta College.
NAME – Parent / Guardian (Please PRINT)
SIGNATURE – PARENT / GUARDIAN DATE
Section E – Completed by Department Supervisor / Department Chair / Administrator/Dean
I recommend that the listed Volunteer be approved to perform these voluntary services (noted in Section A).
NAME – DEPT. SUPERVISOR / CHAIR
(Please Print)
SIGNATURE – DEPT. SUPERVISOR / CHAIR DATE
Section F – Completed by Volunteer – ( IF THE VOLUNTEER WILL BE WORKING WITH MINORS )
VOLUNTEER ACKNOWLEDGEMENT AND NOTICE OF AMENDED EDUCATION CODE SECTION 35021
Volunteer Aides California Education Code 35021
I, , am a Volunteer with MiraCosta Community
(PRINT FULL NAME)
College District. I am not a person required to register as a sex offender.
I declare under
penalty of perjury that I am aware of amended Education Code Section 35021 and its application
and that I am not a registered sex offender nor am I required to register as a sex offender.
SIGNATURE - VOLUNTEER DATE
c
.
Risk Management Use ONLY
Approved - TB Sc
reen
Disapproved
SIGNATURE – DIRECTOR, RISK MANAGEMENT
DATE
SIGNATURE - ADMINISTRATOR / DEAN
DATE
NAME - Administrator / Dean (Please Print)
SIGNATURE - VOLUNTEER
I am currently a student at MiraCosta College:
Yes No
Section G Tuberculosis Screening
SB 1038 (1/1/2017) requires a tuberculosis (TB) risk as
sessment be administered and if risk factors are identified, a TB
test examination be performed by a health care provider to determine that the person is free of infectious tuberculosis.
Contact Health Services, ext. 6675 to arrange for this screening.
(Stats. 1976, c. 1010, § 2, operative April 30, 1977. Amended by Stats.1994, c. 141 (A.B. 3458), § 1; Stats. 2001, c.40 (A.B. 1455), § 1.