Thank you for generously sharing your time and expertise with S.D.C.C.D.
Rev.2014Sept
Date:
To: Frank Fennessey, Risk Manager
Site: District Office, Suite 385
From:
Site:
RE: VOLUNTEER WORKER REGISTRATION FORM
Please Print all Information in Ink and Return Completed Form to Risk Management
Volunteer Name: Date of Birth:
Street Address: City: State: Zip:
Cell Phone Number: Home Phone Number: CSID:
Emergency Contact Person’s Name & Number:
District Site & Department:
Dates of Assignment: Begin Date: End Date:
Hours per Week: Days per week:
Is this volunteer assistant associated with an approved District Program? Yes No
If yes: Program Name:
Summary of Volunteer duties:
Will volunteer:
Operate vehicle? Yes No CDL Number:
Handle hazardous materials? Yes No If yes, describe:
Work under supervision of a District employee? Yes No
Work with juveniles? Yes No
Supervisor’s Name (Print) Supervisor’s Signature Date
Dean/Manager Name (Print) Dean/Manager’s Signature Date
Cleared Live Scan Date ________________________
Risk Management Use Only
Reviewed by: Date:
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