STATE OF CALIFORNIA



STATE OF CALIFORNIA DEPARTMENT OF CORRECTIONS

VOLUNTEER QUESTIONNAIRE

CDC 106 (12/04)

|READ CAREFULLY. Please print or type. The information requested will be used by officials of the Department of Corrections to determine whether your application will be |

|approved or disapproved. The information provided will be maintained in a file in the AWIS Office. |

|Any omission or falsification on this questionnaire may be cause for denial of visiting/volunteering. Please mail this form directly to the Sponsor/AWIS of the institution |

|where you plan to visit/volunteer |

|1. YOUR NAME (FIRST MIDDLE LAST) |HOME TELEPHONE NUMBER/AREA CODE |

| |( ) |

|2. MAIDEN NAME (If applicable) |HAVE YOU EVER USED ANOTHER NAME? IF SO, PLEASE LIST ALL. |

|3. BIRTHDATE (MO/DAY/YEAR) |AGE |4. BIRTHPLACE (CITY, STATE, COUNTRY) |ο Female |

| | | |ο Male |

|5. DRIVERS LICENSE NUMBER AND ISSUING STATE |IDENTIFICATION CARD AND ISSUING STATE |6. SOCIAL SECURITY NUMBER |

|7. PRESENT RESIDENCE ADDRESS (NO. & STREET) (DO NOT USE P.O. BOX) |CITY |STATE |ZIP CODE |

|7A. PRESENT MAILING ADDRESS, IF DIFFERENT THAN RESIDENCE ADDRESS |CITY |STATE |ZIP CODE |

|8. PREVIOUS ADDRESS (NO. & STREET) WITHIN PAST TWO YEARS |CITY |STATE |ZIP CODE |

|9. I VISIT (OR HAVE VISITED) ANOTHER INMATE(S) IN A CALIFORNIA PRISON. |

|ο NO οYES If Yes, complete Item 9A. Attach additional sheet if more than two inmates. |

|9A. INMATE’S NAME |CDC NUMBER |INSTITUTION WHERE YOU VISITED |RELATIONSHIP TO INMATE |

| | | | |

|10. HAVE YOU EVER BEEN ARRESTED, CITED, OR DETAINED FOR ANY OFFENSE/CRIME? |ο NO ο YES |

|If yes, complete item 10A. List all arrests, citations or detainment. Failure to list all may result in denial of volunteering. Attach additional sheets if necessary. |

|10A. OFFENSE |APPROXIMATE DATE |DISPOSITION/DISMISSED, PROBATION, JAIL, PRISON |

| | | |

| | | |

| | | |

| | | |

|TO BE COMPLETED BY INSTITUTION STAFF |

|ο APPROVED ο DISAPPROVED IF DISAPPROVED, the applicant is to be informed in writing of the disapproval. |

|REASON FOR DISAPPROVAL |

|NAME/SIGNATURE |TITLE |INSTITUTION |DATE |

| |Correctional Captain |California Men’s Colony | |

|REVIEWED AND ο APPROVED ο DISAPPROVED BY _________________________________, Associate Warden, Associate Services |

EXPIRATION DATE

|11. Are you on Probation? |Are you on Parole or Civil Addict Outpatient Status? |Are you a Former Inmate? |

| ο NO ο YES | ο NO ο YES | ο NO ο YES |

11A. If you are a former inmate discharged from supervision, you must have the prior written approval of the Warden/Superintendent before visiting will be permitted.

11B. If you are currently on probation, parole or civil addict outpatient status, you must submit a letter signed by your supervising agency and have the written approval of the Warden/Superintendent prior to visiting.

|12. Are you currently under any type of a court imposed program? |13. Do you have any type of metal implant or prosthesis? |

| ο NO ο YES |If yes, please explain on another sheet | ο NO ο YES |If yes, please attach a verifying statement |

| |and attach to this form. | |from your doctor. |

|14. If you are under 18 years of age and not the inmate’s legal spouse, you must have the written notarized consent of a parent or legal guardian and be accompanied by a |

|responsible adult who is also approved to visit. The notarized written consent must be presented each time a minor visits unless prior approval has been obtained from the |

|Warden/Superintendent for an inmate to visit with his or her unchaparoned children. Emancipated minors must provide a copy of the court order. |

|15. The following laws relate to prison visitation: |

| |

|Visitors entering the correctional institution, camp or facility grounds are subject to a search of their person, vehicle and property. Except as described below, visitors |

|may leave the institution, camp or facility grounds rather than submit to a search of their person, vehicle or property. Refusal to submit to the search will result in the |

|denial of visitation for that day. |

| |

|Visitors may not elect to leave the correctional institution, camp or facility grounds rather than submit to a search when institution officials possess a court issued search|

|warrant or cause for a search arises while the visitor is on the institution grounds and the cause for the search is believed by institution officials to be a criminal |

|offense. |

| |

|It is a felony for anyone to assist inmates to escape. Bringing firearms, deadly weapons or explosives on prison grounds, or giving inmates firearms, weapons, explosives, |

|liquor, cocaine, other narcotics, or any kind of drugs, including marijuana, is a felony (Sections 2772, 2790, 4533, 4535, 4550, 4573, 4573.5, 4573.6, 4574, 4600 Penal Code).|

| |

|Giving letters to inmates or taking letters out for inmates by anyone is a misdemeanor (Section 4570 Penal Code). |

| |

|Anyone who falsely identifies himself/herself to gain admission to a prison is guilty of a misdemeanor. Persons previously convicted of a felony in this state who came upon |

|the grounds of a prison without permission of the official in charge are guilty of a felony (Section 4570.5, 4571 Penal Code). |

| |

|Entry on institution property for unauthorized purposes will be considered trespassing as provided in Section 602(j) of the Penal Code. Refusal or failure to leave the |

|property when requested to do so by an official will be considered trespassing as provided in Section 602(p) of the Penal Code. |

| |

|In the event of an emergency situation that affects a significant portion of the inmate population at an institution, the visiting program and other program activities may be|

|suspended during the period of emergency. |

| |

|Hostages will not be recognized for bargaining purposes during attempted escapes by inmates (Section 3304, Title 15, Div. 3, Cal. Adm. Code). |

|16. If you are approved to volunteer, the chaplain will be notified and it is his/her responsibility to notify you. |

| |

|If you are is denied, the institution will notify you by mail. You will not be allowed to volunteer until the application process is complete. |

17. I have read and understand the above information.

SIGNATURE DATE

|SPONSOR’S NAME AND TITLE |SPONSOR’S SIGNATURE |ACTIVITY |

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COMMUNITY VOLUNTEER IDENTIFICATION CARD - oðNEW / oðRENEWING

οNEW / οRENEWING

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