MIRACOSTA COMMUNITY COLLEGE DISTRICT
REQUEST / RECOMMENDATION FOR VOLUNTEER SERVICE
VOLUNTEER Form RM–A Request / Recommendation for Volunteer Service (03/2019)
Prior to ANY service as a Volunteer, approval must be obtained from the District.
A volunteer is a person who: (a) performs services for the district; (b) serves without compensation of any kind; and (c)
is under direct supervision of a district employee. [Reference: Board Policy 7500 / Administrative Procedure 7500
.]
REQUIRED: IMPORTANT Complete all applicable Sections A-G with BOTH Volunteer and Section E Employee present!
"Employee Notice Workers' Compensation Benefits" document andMedical Provider Network”. (See MCC Volunteer website.)
Volunteer prints out and retains. Complete Pages 4 & 7, if needed
Form RM–A Request / Recommendation for Volunteer Service
Upon com
pletion: Department retains a copy for their files.
Original is sent to Director of Risk Management at MS 6
Risk Management will review and either approve or disapprove with e-mail notification to employee listed in Section E.
Form RM–B Volunteer Register (separate form)
Complet
ed by the Volunteer. Approved by the Supervisor at the work site.
Retained by Department Supervisor / Department Chair / Administrator as evidence of the hours
served during the dates of service in Section A of Form RM-A.
NOTE: Fields in Section A must be filled in electronically. If handwritten, document will be returned.
FORM RM–A
Section A Completed by Department Supervisor / Department Chair / Administrator__________________
[This section MUST be filled in electronically.] PRINT NAME HERE
has volunteered to assist
(VOLUNTEERS NAME - PRINT) (DEPARTMENT)
in the following way(s):
It is expected that service will be provided from
to
MAXIMUM ONE (1) YEAR
(mm/dd/yy)
(mm/dd/yy) Not to
exceed June 30
th
Approximate number of hours [Check one] daily weekly monthly
VOLUNTEER MAILING ADDRESS CITY STATE ZIP
VOLUNTEER HOME PHONE VOLUNTEER CELL PHONE VOLUNTEER WORK PHONE DATE
Section B Completed by Volunteer [Please PRINT Name Clearly]
I, , request and acknowledge that the MiraCosta
Community College District shall consider my volunteer services to be deemed as an unpaid employee of
MiraCosta College. I also understand that a fingerprint check and background investigation similar to a regular
school employee may be conducted upon me. I acknowledge that if I am injured while working on behalf of the
District, I will be covered by the District’s Workers’ Compensation coverage. I also understand that my working
status begins and ends when I have signed in and out on the “Volunteer Register” form (Form RM-B) at the work
site. I am responsible for signing in and out every service day. Further, I affirm that, to my knowledge, I am in
good health and physical condition for volunteer service.
Location:
Will volunteer have any contact with students? If so, follow instructions in section G for Tuberculosis screening.
MIRACOSTA COMMUNITY COLLEGE DISTRICT
REQUEST / RECOMMENDATION FOR VOLUNTEER SERVICE
VOLUNTEER Form RM–A Request / Recommendation for Volunteer Service (03/2019)
Section CCompleted 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 DCompleted 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 ECompleted 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 FCompleted 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.