Classified Application Packet Riverside School District by alicejenny

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									RIVERSIDE SCHOOL DISTRICT NO. 416                                                        APPLICATION FOR
34515 N. Newport Highway
Chattaroy, WA 99003                                                                   CLASSIFIED EMPLOYMENT
(509) 464-8201                                                                   Equal Opportunity/Affirmative Action Employer

Full Name:                                                                                            Date:
                   Last                       First                     Middle Initial

Social Security Number (optional):

How were you referred to Riverside SD?                   Riverside SD Web Page           Other Web Page             Employment Agency
                 Please check only one:                  Employee                        Advertisement              Other

PERSONAL INFORMATION
Other name(s) under which records may
be listed. For example, do you have any nicknames,     Last                                   First                             Middle Initial
a shortened first name, or any other name or alias
by which you are referred or by which you refer to
yourself?

Address:                                                                                     Home Phone:
                          # Street                    City          State       Zip                            Area Code       Number
Mailing Address                                                                              Work Phone:
(if different)            # Street                    City          State       Zip                            Area Code       Number
E-mail Address                                                                               Cell Phone:
                                                                                                               Area Code       Number
Person through whom you may be reached:                                                      Contact Phone
                                                      Name                                                     Area Code       Number
Present position:                                                                            Employer Phone
Present employer:                                                                                              Area Code       Number
May we contact your present employer?                        Yes      No           Date you are able to initiate service:

RETIREMENT INFORMATION
         I am not a member of the retirement system in the State of Washington
         I am currently a member of the                          retirement system in Washington State.       Plan #:
         I was previously a member of the                        retirement system in Washington State.
         I separated employment on                               Contributions refunded?             Yes                       No

JOB NUMBER(S) FOR WHICH YOU ARE APPLYING
    Job Number___________________          Job Number____________________            Job Number___________________
Position Title _____________________   Position Title _____________________      Position Title _____________________
Are you interested in substitute work?                    Temporary or Seasonal work?

PROFESSIONAL INFORMATION
Please indicate the position you are applying for:
   Secretary                                  Maintenance                                               Paraprofessional
    Food Service                              Custodian                                                 Grounds
    Professional                              Technical                                                 Other _____________________
Position Number: _____________            Position Title
Are you interested in substitute work?

SPECIAL SKILLS For office/clerical work
Typing (WPM)                Computer Usage (i.e. IBM):
Dictation (WPM)             Software (i.e. Word, Excel):
SPECIAL SKILLS For maintenance or custodial work
Types of Machines operated:                                                                             Years of experience:



List other special training, skills, and experience that you have acquired:
PREVIOUS WORK EXPERIENCE (include military service) (list most recent first)
Employer:                                                                    Dates from – to
Address:
               # Street                                                    City                              State            Zip
Supervisor:                                       Phone                                              Base Salary
Duties:
Reason for leaving:

Employer:                                                                                            Dates from – to
Address:
               # Street                                                    City                              State            Zip
Supervisor:                                       Phone                                              Base Salary
Duties:
Reason for leaving:

Employer:                                                                                            Dates from – to
Address:
               # Street                                                    City                              State            Zip
Supervisor:                                       Phone                                              Base Salary
Duties:
Reason for leaving:

Employer:                                                                                            Dates from – to
Address:
               # Street                                                    City                              State            Zip
Supervisor:                                       Phone                                              Base Salary
Duties:
Reason for leaving:



    Check here if you do not wish the District to contact your present employer unless an offer of employment is made.
    •    Are you a former employee of our District?                     Yes        No
    •    If so, dates and positions: ___________________________________________________
    •    Have you ever been dismissed, discharged or have you separated employment in order to avoid discipline or
         discharge?             Yes        No (Provide an explanation) ___________________________________________________
    ________________________________________________________________________________________________________
    •    Are you presently involved in an employment situation where discharge or discipline is being discussed?                        Yes         No

ACTIVITIES:
•   List professional, trade, business, civic or educational related activities and offices held. (You may exclude memberships which reveal race,
    gender, creed, color, national origin, age, or disabilities).
EDUCATIONAL HISTORY
   School Name                             Location                      Major Course               Dates Attended           Graduated                 Degree
                                          (city, state)                   Or subject                  (from – to)            Yes   No
High School:

Technical/trade School (after high school):

College(s) (list all attended)




Other education/training:




REFERENCES:
(List two past supervisors and at least two persons not related to you who have knowledge of your qualifications for the position for which you are applying.)
 Name/relationship                               # Street                                    City                    State             Zip                Phone
                                                                                                                                                    (include area code)




CERTIFICATION, AUTHORIZATION AND RELEASE
I certify under penalty of perjury under the laws of the State of Washington that the information provided in this entire application is
true and correct. I authorize Riverside School District to conduct a background investigation into my past employment, education,
vocational, and other activities such as my credit and criminal background. To conduct this investigation, I authorize the District to
obtain a consumer report or similar information regarding me to evaluate my suitability for employment. Further, if I am hired, I
authorize the District at any time during my employment, to obtain a consumer report or similar information regarding me for the
purposes of promoting, reassigning, or retaining me as an employee. I understand that a consumer report is a communication by a
consumer reporting agency that bears on a consumer’s character and general reputation, and may include, but is not limited to, credit
checks and criminal background information. I further authorize any current/former employer, person, firm, corporation, educational
or vocational institution, or government agency to provide the District to which I am applying with any information regarding me. I
further authorize the District to disclose any information they may have regarding me if such information is requested by a different
potential future employer of me. I hereby release and discharge said District and those who provide, receive or use such information
from any and all liability as a result of furnishing and receiving this information. I further agree that if an offer of employment is
made to me, I will provide verification of my certification, education and experience. I understand and agree that false or
misleading information, including omissions, in my application or interview(s) shall be just and sufficient cause for dismissal
or refusal to hire. References and personal information that become a part of this application will be regarded as confidential and
shall not be revealed to me. I understand that any offer of employment that may be made to me is conditional and subject to the
acceptable outcome of a criminal history background information check and fair credit reporting; and the approval of the District’s
Board of Directors.


                                        Signature of Applicant                                                                 Date/Place of Signing
IN A SHORT ESSAY FORMAT, PLEASE RESPOND TO THE FOLLOWING:
What are your primary reasons for wanting to work in the Riverside School District?




IN A SHORT ESSAY FORMAT, PLEASE RESPOND TO THE FOLLOWING:
Please describe your work ethic and why you feel you are the best candidate for the position(s) for which you are applying:




IN A SHORT ESSAY FORMAT, PLEASE RESPOND TO THE FOLLOWING:
What are some key experiences you’ve had which would be of value in working with and/or around children?
REMINDER                                                                                  CLASSIFIED APPLICATION PACKET

   • Please use the following checklist as your guide to fulfilling the requirements for a complete application file.
√CHECKLIST
     Mandatory                                                                          Optional
        1.   Complete Riverside School District Application                             Confidential Data Form (Insert C)
        2.   General Cover Letter/Letter of Interest
        3.   Current Resumé
        4.   Disclosure Form (Insert A)
        5.   Confidentiality Form (Insert D)
        6.   Anti-Discrimination From (Insert E)
        7.   Unofficial Copies of College Transcripts (If indicated on posting)
        8.   Immunization History (Insert F)
        9.   Washington State Request for Criminal History (Insert G)




   RIVERSIDE SCHOOL DISTRICT IS A SMOKE AND DRUG/ALCOHOL FREE WORKPLACE.
                                                                                Riverside School District No. 416
Insert A                                                                                      CRIMINAL HISTORY DISCLOSURE

                                                                           (Reference Chapter 28A.400 RCW, Chapter 43.43 RCW)
Name
          Last                                            First                                          Middle

                                    YOU MUST ANSWER ALL QUESTIONS ON THIS FORM
Please complete the following questions and confirm the declaration. Any falsification or misrepresentation including omission of a
material fact or failure to complete any part of the application or this questionnaire shall be grounds for denial of employment, denial
of continued employment, or termination of employment with Riverside School District.

1.   Are you presently charged with, but not convicted of, any crime? (Exclude civil infractions, such as minor traffic
     citations. DUI and DWI convictions are not minor traffic citations and must be reported).             No      Yes
     If yes, include an explanation of the nature of the charge, place, date, and court. A pending criminal charge will not
     necessarily bar you from District employment.

2.   Have you ever been arrested and/or charged with a crime at any time? If yes, as to each arrest, supply the following
     information:   No     Yes

     What was the crime?

     If charged, are the charges still pending? If so, indicate the nature of the charge, date charged, court of jurisdiction, case
     number, and trial date (if scheduled).              No      Yes


     If the charges are not still pending, indicate the nature of the charge, the date charged, the court of jurisdiction, and the
     case number, and specify how the charges were resolved. (Indicate whether by dismissal, acquittal, conviction, guilty plea,
     agreement with court or prosecutor, or some other manner of disposition).

3.   Have you ever been convicted of any crime? (The term “convicted” means all adverse dispositions, including a finding of
     guilty, a plea of guilty or nolo contendere, an Alford plea, a stipulation to facts, a deferred or suspended sentence, or a
     deferred prosecution. Exclude civil infractions, such as minor traffic citations. DUI and DWI convictions are not minor
     traffic citations and must be reported.)            No       Yes

     If yes, include an explanation of the nature of the crime, place, date and court. A conviction record will not necessarily
     bar you from District employment.

4.   Check any of the following for which you have been convicted, including any of these crimes as they may have been
     renamed: (The term “convicted” includes all adverse dispositions, including a finding of guilty, a plea of guilty or nolo
     contendere, and Alford plea, a stipulation to facts, a deferred or suspended sentence, or a deferred prosecution).


       Custodial Assault                        First or Second Degree Manslaughter                        Prostitution
       Patronizing a Juvenile Prostitute        First, Second or Third Degree Assault of a Child           Incest
       Promoting Pornography                    Endangerment with a Controlled Substance                   Unlawful Imprisonment
       Malicious Harassment                     First, Second or Third Degree Assault                      Vehicular Homicide
       Communication with a Minor               Selling or Distributing Erotic Material to a Minor         Aggravated Murder
       First or Second Degree Extortion         First or Second Degree Custodial Interference              First Degree Burglary
       Child Abandonment                        First or Second Degree Custodial Sexual Misconduct         Simple Assault
       First Degree Arson                       First, Second or Third Degree Rape of a Child              Indecent Liberties
       First or Second Degree Kidnapping        Child Abuse or Neglect as Defined in RCW 26.44.020
       First, Second, or Third Degree Rape      Violation of Child Abuse Restraining Order
       First or Second Degree Murder            Sexual Exploitation of a Minor/Commercial Sexual Abuse of a Minor
       Child Buying or Selling                  First or Second Degree Criminal Mistreatment
       First or Second Degree Robbery           First, Second or Third Degree Child Molestation
       Criminal Abandonment                     First or Second Degree Sexual Misconduct with a minor
       Felony Indecent Exposure                 First Degree Promoting Prostitution


       CHECK HERE IF YOU HAVE NOT BEEN CONVICTED OF ANY OF THE ABOVE CRIMES, INCLUDING ANY
     OF THESE CRIMES AS THEY MAY HAVE BEEN RENAMED.
5.   Have you ever been (a) found by a court in a protection proceeding under Chapter 74.34 RCW to have abused or
     financially exploited a vulnerable adult or (b) convicted of the following crimes where the victim was a vulnerable adult
     (vulnerable adult means adults of any age who lack the functional, mental or physical ability to care for themselves):

     •   First, second or third degree extortion
     •   Forgery
     •   First, second or third degree theft
     •   First or second degree robbery
     •   Any of the foregoing crimes as they may have been renamed

         No         Yes    If yes, please explain: ______________________________________________
6.   Have you ever been convicted of any crime involving the manufacture, delivery, or possession with intent to manufacture
     or deliver a controlled substance?

         No         Yes    If yes, please explain: ______________________________________________
7.   Have you even been found in any dependency action under RCW 13.34.040 to have sexually assaulted or exploited any
     minor or to have physically abused any minor?

         No         Yes    If yes, please explain: ______________________________________________
8.   Have you ever been found by a court in a domestic relations proceeding under Title 26 RCW to have sexually abused or
     exploited any minor, or to have physically abused any minor?

         No         Yes    If yes, please explain: ______________________________________________

9.   Have you ever been found in any disciplinary board final decision to have sexually or physically abused any minor or
     developmentally disabled person, or to have abused or financially exploited any vulnerable adult? “Disciplinary board
     final decision” means (a) any final decision by the director of the Department of Licensing for real estate brokers and
     salespersons and (b) any final decision by a disciplinary authority under Chapter 18.130 RCW or the secretary of the
     Department of Health for the following businesses or professions: chiropractic, dentistry, dental hygiene, naturopathy,
     massage, midwifery, osteopathic medicine and surgery, physical therapy, physicians, practical nursing, registered nursing,
     and psychology.

         No         Yes    If yes, please explain: ______________________________________________
10. Are you presently charged with, but not convicted of, any of the crimes or offenses described in questions 1 through 9
    above?

         No         Yes    If yes, please explain: ______________________________________________
11. Have you ever been arrested, charged, or convicted of any crime not otherwise listed?

         No         Yes    If yes, please explain in accordance with questions 1-4 above:
____________________________________________________________________________________________________________
Applicants who have been offered employment will be required to complete a Request For Criminal History Form, will be required to
submit to fingerprinting, and will be required to complete a Washington State Sexual Misconduct Disclosure Release. Applicants
shall be employed on a conditional basis pending completion of the background investigation. Being employed on a conditional basis
means that the District has the absolute right to deny you employment if, in it’s exclusive judgment, your background investigation
results in any basis for the District to decide that your employment is not in the best interest of the District.

An inquiry may be made to the Washington State Patrol, a Federal, or other law enforcement agency to verify your responses to the
above inquiries. A copy of any response received pursuant to such inquiry will be made available to you upon request.

Pursuant to RCW 9A.72.085, I certify under penalty of perjury under the laws of the State of Washington, that the foregoing is true
and correct.

Last Name: ______________________________            First Name: _________________________________

________________________________________             ___________________________________________
Applicant Signature                                  Date/Place of Signing
EMPLOYMENT HISTORY DISCLOSURE
Please complete the following questions and confirm the declaration. Any falsification or misrepresentation including omission of a
material fact or failure to complete any part of the application or this questionnaire shall be grounds for denial of employment, denial
of continued employment, or termination of employment with Riverside School District.

1.   Have you ever been on a plan of improvement or placed on probation with any employer?
       No          Yes If yes, please explain: ______________________________________________
2.   Has any entity or person ever notified you or implied to you that you might be placed on a plan of improvement, placed on
     probation, disciplined, non-renewed, or discharged?
        No           Yes If yes, please explain: ______________________________________________
3.   Have you ever been placed on administrative leave pending investigation of allegations of misconduct with any employer?
       No          Yes If yes, please explain: ______________________________________________
4.   Has any entity or person ever notified you or implied to you that you might be placed on administrative leave pending
     investigation of allegations of misconduct?
        No           Yes If yes, please explain: ______________________________________________
5.   Have you ever been the subject of a complaint to the Superintendent of Public Instruction or any other disciplinary board
     or licensing body?
         No          Yes If yes, please explain: ______________________________________________
6.   Has any person or entity ever notified you or implied to you that you might be the subject of a complaint to the
     Superintendent of Public Instruction or any other disciplinary board or licensing body?
        No         Yes If yes, please explain: ______________________________________________
7.   Have you ever resigned or otherwise separated from any employment (inclusive of regular, part-time, or extracurricular
     positions) in order to avoid discipline, discharge, nonrenewal, threatened discipline, discharge or nonrenewal, or perceived
     future discipline, discharge or nonrenewal?
        No           Yes If yes, please explain: ______________________________________________
8.   Have you ever been disciplined, discharged, non-renewed or threatened to be disciplined, discharged or non-renewed
     from any employment (including regular, part-time, and extracurricular positions)?
        No         Yes If yes, please explain: ______________________________________________
9.   Have you ever had sanctions placed on your teaching certificate for any reason?
       No           Not Applicable          Yes If yes, please explain: ______________________________________________
10. Have you ever had sanctions threatened to be placed on your teaching certificate for any reason?
      No           Not Applicable          Yes If yes, please explain: ______________________________________________
11. Have you ever been denied a teaching certificate anywhere?
      No           Not Applicable          Yes If yes, please explain: ______________________________________________
12. Has any entity or person ever threatened to deny you of a teaching certificate?
      No            Not Applicable          Yes If yes, please explain: ______________________________________________
13. Is disciplinary action currently pending anywhere against you?
        No          Yes If yes, please explain: ______________________________________________
14. Have you ever had an educational or job related license, permit or certificate revoked or suspended, or been subject to
    discipline, from a licensing or certification agency, such as the State Board of Education or Professional Educators
    Standards Board, in this State or any other jurisdictions?
       No           Yes If yes, please explain: ______________________________________________


Pursuant to RCW 9A.72.085, I certify under penalty of perjury under the laws of the State of Washington that the foregoing is true and
correct.

Last Name: ______________________________              First Name: _________________________________

________________________________________               ___________________________________________
Applicant Signature                                    Date/Place of Signing


Employment is contingent upon prospective employees successfully completing a record check through the Washington State
Patrol Criminal Identification System, and the Federal Bureau of Investigation.
                                                                                Riverside School District No. 416
Insert C                                                                              Optional Confidential Data Form

The Riverside School District prohibits discrimination based on race, color, religion, creed, national origin, sex, marital status, age,
sexual orientation, honorably discharged veteran or military status, pregnancy, or the presence of any sensory, mental, or physical
disability or the use of a trained dog guide or service animal by a person with a disability, unless based upon a bona fide occupational
qualification, or any other basis prohibited by law. The District is an equal opportunity employer, supports the spirit, policies and
practices of affirmative action. Your response to the following questions will assist the district in accurately reporting employment
practices to state and federal agencies.

Last Name: __________________________________________ First Name: __________________________________________

Sex/Age              Female                      Male                       Are you over 40 years of age?

Disabled:            No                          Yes – If yes, and you need assistance during the application process, please contact
                                                 our Human Resources Office.

I consider myself a member of the following ethnic group:

                     Asian                      Black/African American                        Hispanic/Latino

                     White/Caucasian             Native Hawaiian/Pacific Islander              More than one race

                     American Indian/Alaskan Native




DISABLED AND VIETNAM-ERA AFFIRMATIVE ACTION PROGRAM
For purposes of affirmative action, this supplemental information is confidential and for measuring workforce diversity and to prevent
discrimination. Your responses will be kept separate from other documents relating to your application. This document will not be
used by the individuals who process your application.

A. Veteran: I am a Veteran of the United States Armed Services.                       Yes               No

B. Vietnam-Era Veteran: The term “Vietnam-Era Veteran” means a person whom 1) served on active duty for a period of more
   than 180 days, any part of which occurred from August 5, 1964, through May 7, 1975, and was discharged or released from active
   duty for reasons other than a dishonorable discharge, or 2) was discharged or released from active duty for a service-connected
   disability incurred during the Vietnam Era.
   I meet the definition provided for “Vietnam-Era Veteran”                         Yes              No

C. Disabled Veteran: The term “Disabled Veteran” means a person entitled to disability compensation under law as administered by
   the Veteran’s Administration for a disability rated at 30 percent or more, or a person whose discharge or release from active duty
   was for a disability incurred or aggravated in the line of duty.
   I meet the definition provided for “Disabled Veteran”                             Yes              No




   RIVERSIDE SCHOOL DISTRICT IS A SMOKE AND DRUG/ALCOHOL FREE WORKPLACE.
Insert D                                                          Riverside School District No. 416

CONFIDENTIALITY STATEMENT

Basic to the maintenance of professional ethics and community respect is the principle of confidentiality. All
staff and volunteers who have access to personal information have a fourfold set of ethical responsibilities, by
which they are bound to the students, Riverside School District and all its buildings, the community and
personal matters will remain confidential; thus we are obliged by law and ethics to honor this trust.

Though not all-inclusive, the following is presented to provide some guidelines concerning the matter of
confidentiality.

   1. Information and details about student matters may be discussed for clinical purposes only. That is,
      personal data may be discussed in clinical and supervisory meetings in order that the matter may be
      more appropriately and therapeutically managed.

   2. No identifying information about the student (names, addresses, Social Security numbers, physical
      disability, etc.) should be revealed except within the school itself with those who have a legitimate “need
      to know”.

   3. Case records should be used for clinical purposes only and not for the general perusal. Other agencies
      requesting the records should first obtain a release for information from the student or guardian. All
      court orders must be immediately referred to the Program Director before any information is provided
      on a student.

   4. Discussing the details of any student/school business outside of the school even though names,
      addresses and Social Security numbers are not revealed could also be considered a breach of
      confidentiality. That is, one might possibly describe in detail, facts about the case and never mention
      who the person is or allude in any way to names or any type of descriptive data, and yet within the
      discussion reveal enough that the listener might possibly identify the student. Thus, the discussing of
      school business outside of the school simply should not be done.

   5. The fact that a school issue has been made public through the news media does not alter the fact that the
      individual still has confidentiality privileges within the school district and all its agencies; thus
      especially in these situations, confidentiality still should be maintained.

Staff and volunteers, who have access to personal information, will sign the following oath and it will be kept in
their personnel file.

       Affirmed this____________________ day of __________________, 20_____.


Name (printed) ____________________________ Signed________________________
Insert E                                                           Riverside School District No. 416
DISCRIMINATION PROHIBITED

In compliance with federal and state regulations, the following is published for your information:

Riverside School District No. 416 requires that its faculty, administration, and staff comply with the spirit and
the law of equal opportunity and nondiscrimination. Individuals having responsibility for admitting students,
employing faculty and staff, administering educational programs and activities are required to comply with the
district’s policy and applicable state and federal laws that prohibit discrimination, to include but not be limited
to:

   1. RCW Chapter 49.60. State of Washington, Law Against Discrimination, RCW Chapter 49.60, prohibits
      discrimination because of race, creed, color, national origin, honorably discharged veteran or military
      status, sex, marital status, age, sexual orientation, or the presence of any sensory, mental, or physical
      disability or the use of a trained dog guide or service animal by a person with a disability.

   2. Title VI of the Civil Rights Act of 1964 prohibits discrimination against students on the basis of race,
      color, or national origin in the operation of any federally-assisted program.

   3. Title VII of the Civil Rights Act of 1964, as amended by the Equal Employment Opportunity Act, 1972,
      prohibits discrimination in employment on the basis of race, color, sex, religion, or national origin.

   4. Regulation implementing Title IX of the Education Amendments of 1972 states:

               “. . . No person shall, on the basis of sex, be excluded from the participation in, be denied the
               benefits of, or be subjected to discrimination under any academic, extracurricular, research,
               occupational training, or other education program or activity operated by a recipient which
               receives or benefits from federal financial assistance.”

   5. Chapter 392-190 WAC, Equal Educational Opportunity – Sex Discrimination Prohibited. This state law
      prohibits any public school district from discriminating on the basis of sex with regard to any activity
      conducted by or in behalf of a school district including, but not limited to, preschool, adult education,
      community education, and vocational-technical program activities.

   6. Regulation implementing Section 504 of the Rehabilitation Act of 1973 prohibits discrimination on the
      basis of handicap in any program or activity which receives or benefits from federal financial assistance.

Persons having special concerns in this regard should contact the Superintendent for Riverside School District
No. 416, who has been designated to coordinate the district’s equal opportunity compliance efforts, 34515
North Newport Highway, Chattaroy, Washington 99003, (509) 464-8201.



___________________________________                   _____________________________
Signature                                             Date
Insert F                                                                               IMMUNIZATION HISTORY FOR SCHOOL PERSONNEL



Name: __________________________________________                                       Birth date: ________________________
Position: ________________________________________                                     ID #: _____________________________


      1.             Provide Immunization Dates (for those born on or after 1/1/57 for measles and mumps, on or after 1/1/ 80 for varicella)

                         Immunization                               Vaccine                    Month                Day                Year
                                MMR                                 MMR DOSE 1
                          Measles (Rubeola),                        MMR DOSE 2
                          Mumps & Rubella                    MMR DOSE 3 (NOT REQUIRED)
                                                                     MEASLES
                                                                      MUMPS
                                                                     RUBELLA
                     Varicella (Chickenpox)                       VACCINE DOSE 1
            If documentation of disease (born 1/1/80 or           VACCINE DOSE 2
            later) must be done by licensed healthcare            DISEASE
                          provider (LHP)

                                                            LHP Signature:
                                                                                OR
      2.             Have your Licensed Healthcare Provider (LHP) verify your immunity (disease or titer/lab work) (if you don’t meet the age
             requirements)


            Disease                    Disease/Titer                          LHP Signature                                       Date
            Measles                       Disease         Titer

            Mumps                         Disease         Titer

            Rubella                       Disease         Titer

            Varicella                     Disease         Titer

            Other (specify)               Disease         Titer



                                                                                OR
      3.             Attach laboratory verification of titer results (if you don’t meet the age requirements)

                                                                                                                                               --------------------
                         I certify that the information provided here is correct and verifiable                                                --------------------
                                                                                                                                               --------------------
                    X _________________________________________________________________ Date: _______________________                          --------------------
-------------------------------------------------------------------------------------
 I request an exemption for the following reasons as outlined in Policy 6512:          Religious      Medical       Personal
I understand that in the event of an outbreak of a vaccine-preventable disease from which I have been exempted, I may be excluded from work for
the duration of the outbreak.
_____________________________________________                                ___________________
Employee Signature                                                            Date
                                                                                                Riverside School District No. 416
 Insert G                                                                                                Applicant Disclosure Statement


                                            WASHINGTON STATE PATROL
                                                            Identification and Criminal History Section
                                                            PO Box 42633, Olympia, WA 98504-2633
                               REQUEST FOR CRIMINAL HISTORY INFORMATION
                                  CHILD/ADULT ABUSE INFORMATION ACT
                                       RCW 43.43.830 through 43.43.845
                                                                     (Instruction of Reverse Side)

A       REQUESTING AGENCY/ADDRESS                                                                 B     PURPOSE

            Riverside School District No. 416
Agency
                                                                                                  X    ESD/School District Volunteer – no fee
            Valerie Lukens                                                                        □    Non-Profit Busn./Org. – no fee (Excluding
Attn.                                                                                                     Schools & ESD’s)
            34515 N. Newport Highway
Address                                                                                           □    Profit Business/Org. - $10
            Chattaroy, WA 99003
City/State/Zip
                                                                                                  □    Adoptive Parent - $10

          I certify this request is made pursuant to and for the purpose indicated.
                                                                                                  Fees:
                                                                                                  Make payable to Washington State Patrol by cashier’s
          ____________________________________________________________                            check, money order, or commercial business account.
          Authorized Signature                           Date
                                                                                                     NO PERSONAL/CERTIFIED CHECKS ACCEPTED
             District Security Officer______________________________________
          Title




C         APPLICANT OF INQUIRY

Applicant’s Name:
                              Last                                                    First                                       Middle
Alias/Maiden Name:

Date of Birth:                                                               Sex:                              Race:
                                       Month/Day/Year
Social Security Number:                                                       Driver’s Lic. Number/ State:

Secondary dissemination of this criminal history record information response is prohibited unless in compliance with RCW 10.97.050.


                                          IDENTIFICATION DECLARING NO EVIDENCE
D
                            WASHINGTON STATE PATROL IDENTIFICATION & CRIMINAL HISTORY SECTION
      (THIS PORTION MAILED BY REQUESTING AGENCY)                                                                  WSP Use Only
 As of this date, the applicant named below shows no evidence pursuant
                   to RCW 43.43.830 through 43.43.845.

Requesting Agency
                                                                                                             Valid Two Years From Issue

Applicant’s Signature
                                                                                                             Right Thumb Print (Optional)

Applicant’s Name

Address

City/State/Zip
INSTRUCTIONS
                                      Please type or print clearly in ink

SECTION A:      Please type, stamp, or clearly print the address to which our response is to be mailed, and sign.


SECTION B:      Check appropriate box indicating purpose of request.
                Child/Adult Abuse Information: Response limited to convictions of crimes against children or other persons,
                dependency proceedings, abuse of vulnerable adults, and DOL disciplinary board final decisions and any subsequent
                criminal charges associated with the conduct that is the subject of the disciplinary board final decision. The
                business or organization shall use this record only in making the initial employment or engagement decision.
                Further dissemination or use of the record is prohibited. A business or organization violating this subjection is
                subject to a civil action for damages.


SECTION C:      For our search purposes, please provide as much information as possible. Name and date of birth are mandatory.


SECTION D:      Please type or clearly print Business/Organization requesting information, name and address of applicant of inquiry.
                A legible inked right thumb print is optional; however, if submitted, it will be used for positive verification. This
                portion will be returned to the applicant by the requesting agency.


FEES:           Make payable to Washington State Patrol by cashier’s check, money order, or commercial business account.
                Personal/certified checks will not be accepted.


ADDITIONAL INFORMATION: If submitting an applicant fingerprint card, this form is not required.


                PLEASE MAIL ENTIRE              WASHINGTON STATE PATROL
                COMPLETED FOR TO:               Identification Section
                                                PO Box 42633
                                                Olympia, WA 98504-2633



FOR FURTHER INFORMATION, CONTACT THE WASHINGTON STATE PATROL AT (206) 705-5100.




                                           This upper portion sent by WSP to the Agency/Requestor

                                        This lower portion sent by Requesting Agency to the Applicant




This identification certificate is the result of a request for criminal conviction record information from the
Washington State Patrol Identification and Criminal History Section on a prospective applicant by a business o
organization. Pursuant to the Child/Adult Abuse Information Act, RCW 43.43.830 through 43.43.845, if the
conviction record, disciplinary board final declaring the showing of no evidence shall be issued to the applicant.
                             Riverside School District No. 416
                                   FINGERPRINT REQUIREMENTS
                                  FOR SCHOOL DISTRICT EMPLOYEES
                                         AND SUBSTITUTES
 (Fingerprints are required only if offered the position for which you are applying, including substitute work.)

   Washington State Law (RCW 28A.400) now requires that any person hired after June 11, 1992 by a
           school district must be fingerprinted for a state and national background check.


What you need to do…….
If you are hired, you will be required to go to ESD 101 in Spokane and have your fingerprints taken. We will
provide you with further instructions for completing this process.

The cost, including local processing and state-mandated fees, is $71.25 for school district employees. Each
employee is responsible for paying their own fingerprint fees.




I CERTIFY THAT I HAVE THOROUGHLY READ AND UNDERSTAND THE CONTENTS OF THE APPLICANT

DISCLOSURE FORM AND THE FINGERPRINT REQUIREMENTS AS DESCRIBED ABOVE, INCLUDING THE LAW,

RULES AND REGULATIONS RELATING TO FINGERPRINTING.



IN THE EVENT THAT I AM OFFERED A POSITION WITH THE RIVERSIDE SCHOOL
DISTRICT, I UNDERSTAND THAT MY EMPLOYMENT IS OFFERED CONTINGENT UPON A
SATISFACTORY BACKGROUND CHECK. I HEREBY SUBMIT TO A FINGERPRINT CHECK AS
EXPLAINED.


SIGNATURE OF APPLICANT                                      DATE

								
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