Fair Oaks Recreation & Park District - Instructor Questionnaire

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Instructor Background Confidential Questionnaire

Applicant Information

First name *

Last name *

Email *

Mobile *

Address

City

State/Province

Zip/Postal code

Other phone (home or work)

Applicant’s ID Number (California ID or Drivers’ License): *

Section 5164 of the Public Resources Code of the State of California prohibits the Fair Oaks Recreation & Park District from hiring a person for employment at, or hiring a volunteer to perform services at, any of its parks, playgrounds or recreational centers used for recreational purposes in a position having supervisory or disciplinary authority over any minor, if the person has been convicted of certain crimes under the California Penal Code. Section 5164 also authorizes the Fair Oaks Recreation & Park District from to screen any such prospective employee or volunteer for his or her criminal background. In light of your interest in being hired by the Fair Oaks Recreation & Park District from for employment at, or being hired as a volunteer to perform services at, any of its parks, playgrounds or recreational centers used for recreational purposes, in a position having supervisory or disciplinary authority over any minor, and in order to give effect to Section 5164 of the Public Resources Code of the State of California, please answer the following supplemental questions:

Please Note: Having a conviction record may not necessarily prevent volunteering. The nature of the conviction and length of time which as passed since the conviction will be taken into consideration, along with the current Fair Oaks Recreation & Park District’s from policies.

Question 1: *

Have you ever been convicted of violation or attempted violation of any of the statutes specified in Public Resources Code Section 5164 (copy attached), including conviction for violation or attempted violation of an offense committed outside the State of California, if the offense would have been a crime as defined in the statutes referred to if committed in California? This question does not refer to a misdemeanor conviction as defined in Part B of Attachment A (copy attached), unless you have three or more misdemeanor convictions, a felony conviction, or were incarcerated for any of those crimes listed within the preceding ten (10) year period.

Yes No x Clear

If your answer is Yes, please describe the crime(s) of which you were convicted, the date upon which you were convicted and the jurisdiction in which you were convicted:

Question 2: *

Are you willing to be fingerprinted in order that Fair Oaks Recreation & Park District may screen you for a criminal background?

Yes No x Clear

Question 3: *

Without in any way limiting the foregoing, have you ever been convicted of any crime involving an assault with intent to commit a felony, any crime against a person involving sexual assault, any crime against public decency and good morals, disorderly conduct, annoying or molesting a child under age 18, kidnapping, robbery or carjacking?

Yes No x Clear

If your answer is Yes, please describe the crime(s) of which you were convicted, the date upon which you were convicted and the jurisdiction in which you were convicted:

Question 4: *

Are you currently released on bail or on your own recognizance for any crime?

Yes No x Clear

If your answer is Yes, please describe the crime(s) of which you were convicted, the date upon which you were convicted and the jurisdiction in which you were convicted:

Background Investigation Agreement and Declaration

I authorize Fair Oaks Recreation & Park District from to perform a thorough background investigation on all matters related to my suitability for volunteering including online background checking, and to run a fingerprint background check to screen for criminal background. I authorize investigation of all statements contained in my volunteer application. I authorize Fair Oaks Recreation & Park District from to secure information about my background and experience with former employers, current employers, education institutions and any relevant agencies, and authorize those parties to provide information to Fair Oaks Recreation & Park District from concerning my background and experience. I release Fair Oaks Recreation & Park District from and all parties providing information to Fair Oaks Recreation & Park District from about my background and experience from any liability whatsoever arising therefrom.

I, (Applicant Name - entered below) , in seeking to be a volunteer by the Fair Oaks Recreation & Park District from to perform services at, any park, playground or recreational center used by the Fair Oaks Recreation & Park District from for recreational purposes, in a position having supervisory or disciplinary authority over any minor, hereby declare under penalty of perjury that the foregoing is true and correct and that this declaration is executed at:

(City - entered below) , California on (Date - entered below)

Agreement and Declaration - "Applicant Name"

First name *

Last name *

Agreement and Declaration - "City" *

Agreement and Declaration - "Applicant Date" *

Electronic Signature of Applicant*

I acknowledge and agree that should any of my answers to the foregoing questions be subsequently determined to be false and not true, the Fair Oaks Recreation & Park District can immediately terminate my employment by it or cease allowing me to perform voluntary services, without notice. I hereby agree to indemnify and hold harmless the Fair Oaks Recreation & Park District from, its directors, agents and employees, from any and all claims, causes of action, suits, actions, damages, losses or liability arising out of termination of my volunteer services rendered to the Fair Oaks Recreation & Park District from which may occur should any of my answers to the foregoing questions be subsequently determined to be false and not true and/or untrue

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ATTACHMENT A

PROHIBITED OFFENSES UNDER CALIFORNIA PENAL CODE

Part A

A recreation and park district shall not hire anyone for employment in a position with supervisory or disciplinary responsibility over minors (either for pay or as a volunteer) if the person has been convicted of any violation or attempted violations of Section 220, 261.5, 262, 273a, 273d, or 273.5 of the Penal Code, or any sex offense listed in Section 290 of the Penal Code, except for the offense specified in subdivision (d) of Section 243.4 of the Penal Code.

The offenses outlined in this subsection are:

220 Assault with intent to commit mayhem, rape, sodomy, oral copulation, rape in concert with another, lascivious acts upon a child, or penetration of genitals or anus with foreign object (except assault to commit mayhem)

261 Rape

261.5 Unlawful sexual intercourse with a female under age 18

262 Rape of spouse

264.1 Rape or penetration of genital or anal openings by foreign object, etc.; acting in concert by force or use of force

266 Inveiglement or enticement of unmarried female under 18 for purposes of prostitution; aiding and abetting; procuring a female for illegal intercourse by false pretenses

266c Unlawful sexual intercourse, sexual penetration, oral copulation, or sodomy; consent procured by false or fraudulent representations with intent to create fear

266h(b)Pimping a minor

266i Pandering a minor

266j Procurement of child under age 16 for lewd or lascivious acts

267 Abduction of person under 18 for purposes of prostitution

269 Aggravated sexual assault of a child

272 Causing, encouraging, or contributing to the delinquency of persons under 18 years

273a Willful cruelty or unjustifiable punishment of child; endangering life or health

273.d Corporal punishment or injury of a child

273.5 Corporal injury of spouse or cohabitant of opposite sex

285 Incest

286 Sodomy

286.5 Sexually assaulting an animal

287 Sodomy

288.5 Continuous sexual abuse of a child

288 Lewd or lascivious acts with child under 14

288a Unlawful oral copulation

288.2 Harmful matter sent with intent of seduction of minor (FELONY ONLY)

289 Genital or anal penetration with a foreign object

311.1 Sent or brought into state for sale or distribution; possessing, preparing, publishing, producing,

developing, duplicating, or printing within state; matter depicting sexual conduct by minor.

311.2 Sending, receiving, printing, exhibiting, distributing materials depicting sexual conduct by a minor

311.3 Depicting by film, photograph, videotape, etc., sexual conduct by a person under 14

311.4 Employment of a minor to perform prohibited acts

311.10 Advertising for sale or distribution of materials depicting a person under age 18 engaging in or simulating sexual conduct

311.11 Possession or control of material depicting a person under 14 engaging in or simulating sexual conduct

314 Lewd or obscene conduct, indecent exposure, obscene exhibition

647a Engaging in or lewd or dissolute conduct in a public place or in any place open to the public

647d Loitering in or about a public toilet for the purpose of engaging in or soliciting a lewd or lascivious or unlawful act

647.6 Annoying or molesting a child under 18

This section also includes anyone committed as a mentally disordered sex offender under the Welfare and Institutions Code.

Part B

A recreation and park district shall not hire (either for pay or as a volunteer) anyone for employment in a position with supervisory or disciplinary responsibility over minors if the person has been convicted of any felony or misdemeanor specified in Chapter 3 (commencing with Section 207) of Title 8 of Part 1 of the Penal Code, Section 211 or 215 (if a deadly or dangerous weapon was used, as provided in subsection (b) of Section 12022), Section 217.1 or Section 236 of the Penal Code, any offense specified in Chapter 9 (commencing with Section

240) of Title 8 of Part 1 of the Penal Code, or any offense specified in subdivision (c) of Section 667.5 of the Penal Code within ten years of the date of the employer’s request.

If the conviction for any specified felony is over ten (10) years old, then a recreation and park district shall not hire (either for pay or as a volunteer) anyone for employment in a position with supervisory or disciplinary responsibility over minors if the person has been incarcerated for the offense within ten (10) years of the date of the request.

No record of a misdemeanor conviction will be transmitted, unless the person has a total of three (3) or more misdemeanor convictions, or a combined total of three (3) or misdemeanor and felony convictions, or has been incarcerated for any violation in this section within the preceding ten (10) years.

207 – 210 (+ 12022) Kidnapping

211 (+12022) Robbery

215 (+12022) Carjacking

Section 207-210, 211 and 215 apply only if accompanied by a concurrent finding under Section 12022 that a deadly or dangerous weapon was used in the commission of the crime.

217.1 Assault on public official

236 False imprisonment

237 False imprisonment

240 Assault

241.1 Assault upon custodial officer

241.2 Assault on school property

241.3 Assault against transportation personnel or passenger

241.4 Assault on peace officer of school district

241.7 Assault against jurors

242 Battery

243.1 Battery against custodial officer in performance of duties

243.2 Battery on school property

243.3 Battery against transportation personnel or passenger

243.4 Sexual battery

243.5 Assault or battery on school property

243.6 Assault or battery on process server

243.7 Battery against jurors

244 Assault with caustic chemicals

244.5 Assault with stun gun or laser

245 Assault with deadly weapon or force likely to produce great bodily injury

244.2 Assault with deadly weapon or force likely to produce great bodily injury on transportation personnel or passenger

245.3 Assault with deadly weapon or force likely to produce great bodily injury on custodial officer

246 Shooting at inhabited dwelling house, occupied building or vehicle, or inhabited house, car or camper

247 Shooting at unoccupied aircraft or motor vehicle

247.7 Discharge of laser at aircraft

667.5 Sentencing enhancements for various crimes of violence

Public Resource Code 5164

(a) (1) A county or city or city and county or special district shall not hire a person for

employment, or hire a volunteer to perform services, at a county or city or city and county or special district operated park, playground, recreational center, or beach used for recreational purposes, in a position having supervisory or disciplinary authority over any minor, if that person has been convicted of any offense specified in paragraph (2).

(2) (A) Violations or attempted violations of Section 220, 261.5, 262, 273a, 273d, or

273.5 of the Penal Code, or any sex offense listed in Section 290 of the Penal Code, except for the offense specified in subdivision (d) of Section 243.4 of the Penal Code.

(B) Any felony or misdemeanor conviction specified in subparagraph (C) within 10 years of the date of the employer’s request.

(C) Any felony conviction that is over 10 years old, if the subject of the request was incarcerated within 10 years of the employer’s request, for a violation or attempted violation of any of the offenses specified in Chapter 3 (commencing with Section 207) of Title 8 of Part 1 of the Penal Code, Section 211 or 215 of the Penal Code, wherein it is charged and proved that the defendant personally used a deadly or dangerous weapon, as provided in subdivision (b) of Section 12022 of the Penal Code, in the commission of that offense,

Section 217.1 of the Penal Code, Section 236 of the Penal Code, any of the offenses specified in Chapter 9 (commencing with Section 240) of Title 8 of Part 1 of the Penal Code, or any of the offenses specified in subdivision (c) of Section 667.5 of the Penal Code, provided that no record of a misdemeanor conviction shall be transmitted to the requester unless the subject of the request has a total of three or more misdemeanor convictions, or a combined total of three or more misdemeanor and felony convictions, for violations listed in this section within the 10-year period immediately preceding the employer’s request or has been incarcerated for any of those convictions within the preceding 10 years.

(b) (1) To give effect to this section, a county or city or city and county or special district shall require each such prospective employee or volunteer to complete an application that inquires as to whether or not that individual has been convicted of any offense specified in subdivision (a). The county or city or city and county or special district shall screen, pursuant to Section 11105.3 of the Penal Code, any such prospective employee or volunteer, having supervisory or disciplinary authority over any minor, for that person’s criminal background.

(2) Any local agency requests for Department of Justice records pursuant to this subdivision shall include the prospective employee’s or volunteer’s fingerprints, which may be taken by the local agency, and any other data specified by the Department of Justice. The request shall be made on a form approved by the Department of Justice. No fee shall be charged to the local agency for requesting the records of a prospective volunteer pursuant to this subdivision.

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4150 Temescal Street, Fair Oaks, CA, 95628, US 916-966-1036

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