CLASSIFIED SUBSTITUTE APPLICATION Ferndale School District

Transcription

CLASSIFIED SUBSTITUTE APPLICATION
Ferndale School District
PLEASE NOTE: The school district accepts applications for regular continuing or temporary positions only when job openings are available. If you are applying for a regular or temporary position posted within our school district you must complete a regular Ferndale School District Application and follow the outlined instructions it contains. Thank you for your interest in working for our school district. This application is good for most non-teaching
SUBSTITUTE positions, including Para-Educator, Custodial, Clerical, Food Service, Bus Drivers, etc. Before you
will be allowed to begin training or working all application paperwork must be presented in person BY
APPOINTMENT ONLY to Jeanie Forwoodson at the District Office located at 6041 Vista Dr., Ferndale WA,
98248. If you have any questions about this process or would like to schedule an appointment, contact Jeanie at
(360) 383-9232
Classified Application Paperwork:
Application Authorization to Check Work History Pre-‐Employment Background Questionnaire Applicant Disclosure Abuse form Tobacco/Drug ȂFree form (please sign both sides) Technology Resources Use Agreement List of school districts worked for 1 sexual misconduct release form for each school listed on the previous form Retirement Status form (top section only) W-‐4 Withholding form I-‐9 Employment Eligibility Verification form I-‐9 documentation Ȃ Examples of acceptable documents include a social security card and driver's license, social security card and birth certificate, or a US passport. Please see the back of the I-‐9 form for a complete list of acceptable documents. Electronic Direct Deposit Form Voided check for the Electronic Direct Deposit Form Employee Access Signup Form (OPTIONAL Ȃ we no longer send out detailed check information via mail. If you want access to your information online, please sign up using this form). High School Diploma and College Transcripts (if applicable) Possible Required Additional Items Ȃ depending on the department (see below) Food Services ǯ Clerical Typing, Math & Proofreading tests Transportation Drivers Abstract Completed fingerprint card and check for $43.50 made payable to OSPI (see below) WHEN DO I NEED TO DO THE FINGERPRINTING? When the Department you are applying to indicates to you that you are
eligible for further training or consideration as a substitute. At that time make an appointment for fingerprinting.
FINGERPRINTING NOTE ² If you go to Ferndale Police Department to have your fingerprints taken, the fingerprinting fee is
waived. However, the background check itself will cost $43.50, payable to OSPI. A check for this amount needs to be turned
in with your completed fingerprint card to the District Office. You can call the Ferndale Police Department at 384-3390 to
make your appointment.
FERNDALE SCHOOL DISTRICT #502
P.O. Box 698, 6041 Vista Drive
Ferndale, WA 98248
ATTN: Classified Personnel
Position Applying For _____________________
Please check all that apply!
Full - Time
Bus Driver
Custodial Maint.
Grounds Maint.
Food Service
(360) 383-9232
Yes / No
Part-Time
Yes / No
Substitute / On-Call
Yes / No
Secretary
Para-Educator
PERSONAL DATA
Name
Date of Application
Last
First
Middle
Address
Home Phone
(
)
Alternate Phone
(
)
Street
City
State
Zip
Social Security #
Email:
--
--
EXPERIENCE WITH COMMUNITY AND YOUTH GROUPS
REFERENCES
List references, excluding relatives, who may be contacted
Name
Equal Opportunity Employer
Street Address, City, State, Zip
Telephone
Occupation
Page 1
EXPERIENCE
List your most recent employment first. If additional space is needed, attach a separate sheet of paper.
May we contact the employers listed below?
YES / NO
If not, indicate which one(s) you do not wish us to contact.
Month & Year
From
To
Employer / Address
Position
Held/Duties
Reason for
Leaving
Supervisor(s) Name /
Phone No.
Page 2
EDUCATION
Name of High School
Location
Did you Graduate?
Yes
G.P.A.
No
College or University
Location
Dates
Degree
Major
Other Education
Location
Dates
Degree
Major
OTHER
Are you able to perform the duties and tasks of the position for which you are applying with or
without reasonable accommodation or assistance?
With accommodation or
assistance
Without
accommodation or
If accommodation or assistance would be required, please explain how you would perform the
duties and tasks, and with what accommodation.
During the past seven years, have you been convicted of any crime or been released
from prison? _______ If yes, please describe fully. An affirmative answer does not
necessarily disqualify you from employment.
Page 3
CUSTODIAL / MAINTENANCE SKILLS
Skill
YES
NO
Degree of Proficiency
Plumbing
Electrical
Control Technician
Carpentry
Custodial
OTHER
List the area(s) for which you have a journeyman rating:
GROUNDS MAINTENANCE SKILLS
Skill
YES
NO
Lawn Care
Pruning
Control Spraying
Landscaping
Equipment Maintenance
OTHER
List the area(s) for which you have a journeyman rating:
PARA - EDUCATOR SKILLS / ACCOMPLISHMENTS
Skill
YES
State Core Competency Requirements
met? (test or associates degree)
AA Degree Earned?
Experience working with special
needs/troubled youth?
Training in De-Escalation/Anger
Management?
Academic mentoring/tutoring (specify
subject and levels)?
Experience supervising youth in a
classroom or playground activities?
NO
Degree of Proficiency / Experience
OTHER
Page 4
LICENSES / CERTIFICATES
Type of License / Certificate
YES
NO
Expiration
Date
Endorsements
Washington State School Bus Drivers' Certificate
Specify date of most recent bus driver in-service
course
DATE ___________ LOCATION __________________
List any moving violations in the last three years
Have you taken the Bellingham Vocational
Technical Institute's Bus Driver course?
LOCATION
_________________
Valid First Aid Card
Washington State Driver's License
Food Handlers' Permit
OTHER
OFFICE / CLERICAL / ACCOUNTING SKILLS
Skill
YES
NO
Keyboard Speed
w.p.m. ____________
Shorthand / Transcription
&RPSXWHUVDQG%UDQG0DF3&«
Word processor (and Brand)
Database and Spreadsheets (and Brand)
Other Software Used (please specify)
10 Key (by sight or touch?)
Sight
Touch
Fax Machine
Copy Machine
Multi-Line Telephones
Customer Service
Are you more comfortable in slow or
fast paced environments? Do you work
better alone or on a team? Supervised
or Unsupervised?
OTHER
Page 5
PERSONAL GOALS
In the spaces below, please state why you desire employment with the Ferndale School District
and any other skills/qualifications not listed above that you bring to this position.
NOTICE
Pursuant to Chapter 486, Laws of 1987, an inquiry will be made to the Washington State Patrol or a Federal law
enforcement agency to determine whether a perspective employee has been (1)(a) convicted of any offense against
persons; (b) found in any dependency action under RCW 13.34.030; (c) to have sexually assaulted or exploited any
minor or to have physically abused any minor; or (d) found in any disciplinary board final decision. Any response
received from the Washington State Patrol or a Federal law enforcement agency pursuant to such inquiry will be made
available to the individual.
I certify that the information listed on the application is accurate and true. Further, I understand
the district will request a background check for perspective employees through the Washington
State Patrol and FBI pursuant to Chapter 486, Laws of 1987.
Date
Signature
Ferndale School District complies with all state and federal rules and regulations and does not discriminate on the
basis of sex, race, creed, religion, color, national origin, age, veteran or military status, sexual orientation, gender
expression or identity, disability, or the use of a trained guide dog or service animal and provides equal access to the
Boy Scouts and other designated youth groups. This holds true for all district employment opportunities.
Page 6
Ferndale School District No. 502
Optional Confidential EEO Data Form
The Ferndale School District complies with all state and federal rules and regulations and
does not discriminate on the basis of sex, race, creed, religion, color, national origin, age, veteran
or military status, sexual orientation, gender expression or identity, disability, or the use of a
trained guide dog or service animal and provides equal access to the Boy Scouts and other
designated youth groups except as may be necessary to meet a bona fide occupational
qualification. The District is an equal opportunity employer, supports the spirit, policies, and
practices of affirmative action, and has implemented programs to address the diversity of its
workforce.
A response to the following questions will assist the District in accurately reporting its
employment practices to state and federal agencies and complying with the District's affirmative
action plan. Providing this information is strictly voluntary and it shall be maintained as
confidential. The completed data form will be kept separate from other personnel records, and
data on protected status shall not be recorded on any record that is kept in an employee or
applicant's personnel file.
Date: ____________________________
Name: _______________________________________________________________________
Position Applied For: __________________________________________________________
Sex:
Female
Male
Race/Ethnicity: The current legal definition of each racial/ethnic group is provided below.

American Indian or Alaskan Native: persons having origins in any of the original peoples
of North, Central, or South America and who maintain tribal affiliation or community
attachment.

Asian or Pacific Islander: persons having origins in any of the original peoples of the Far
East, Southeast Asia, the Indian Subcontinent, or the Pacific Islands.

Black or African-American (not of Hispanic origin): persons having origins in any of the
Black racial groups of Africa.

Hispanic or Latino: persons of Mexican, Puerto Rican, Cuban, Central or South
American, or other Spanish culture or origin, regardless of race.

White (not of Hispanic origin): persons having origins in any of the original peoples of
Europe, the Middle East, or North Africa.
February, 14
FERNDALE SCHOOL DI STRI CT NO.502
Ferndale, Washington
AUTHORI ZATI ON TO CHECK WORK HI STORY
I authorize Ferndale School District to check my references and to investigate any information provided
in my application for employment. I further authorize my past employers or anyone with information
about my work history, education or qualifications to provide such information to Ferndale School
District in response to their inquiry. I agree to hold harmless from any liability (suit, claim or other action)
anyone supplying such information to Ferndale School District.
Should I become employed by Ferndale School District and at some future time leave said employment,
my signature below further authorizes Ferndale School District to release information regarding my
performance to any potential future employer.
Signed:
(Applicant Name Printed or Typed)
Date
Ferndale School District No. 502
PO Box 698
Ferndale, WA 98248
(360) 383-9206 Fax (360) 383-9201
PRE-EMPLOYMENT BACKGROUND QUESTIONNAIRE
Please complete the following questions and sign the declaration. Any falsification or deliberate misrepresentation, including omission
of a material fact or failure to complete any part of your application or this questionnaire can be grounds for denial of employment or
continued employment with the Ferndale School District.
ALL REQUIRED DOCUMENTATION REQUESTED BELOW MUST ACCOMPANY THIS FORM. ALL QUESTIONS MUST
BE ANSWERED. IF ADDITIONAL SPACE IS NEEDED, ATTACH A SEPARATE SHEET OF PAPER.
SECTION I – PERSONAL INFORMATION (please print or type)
1.
NAME:
2.
ADDRESS:
(Complete mailing address)
3.
TELEPHONE:
4.
Please list all former names (a) you have used when working for another employer, or (b) by which you are known to
reference. If you have more than three, list them on a separate sheet of paper.
(
)
Business
(
)
Home
SECTION II – PROFESSIONAL FITNESS
(If you answer "yes" to questions 1 through 4, on a separate sheet of paper, give a complete explanation, including duties,
circumstances, and any supporting documentation.
Yes
No
1. Have you ever been dismissed, discharged or fired from any employment?
2. Have you ever resigned from or otherwise left any employment while allegations of misconduct on your part were
pending or under investigation?
3. Have you ever been disciplined by a past or present employer because of allegations of misconduct?
4. Are you currently or have you ever been the subject of any investigation or inquiry by an employer because of
allegations of misconduct on your part?
SECTION III – CRIMINAL HISTORY
Yes
No
1.
2.
Have you ever been convicted of any crime? (Note: For the purpose of this question "convicted" includes (a) all
instances in which a plea of guilty or nolo contendere is the basis of conviction, and (b) all proceeding in which
a sentence has been suspended or deferred.) You need not list traffic violations for which a fine or forfeiture of
less than $150.00 was imposed.
a.
Do you currently have any outstanding criminal charges or warrants of arrest pending against you in
Washington?
b.
Do you currently have any outstanding criminal charges or warrants of arrest pending against you in
any other state, province, territory, and/or country?
If you answered "yes" to questions l or 2 of Section Ill, please provide the following:
a.
b.
c.
d
e.
f.
g.
A detailed statement including what occurred, the nature of the offense, charge or warrant;
The name and address of the arresting agency;
The date of the arrest;
The final disposition, if any;
If a court was involved, the name and address of the court;
The complete arrest report and sentence and judgment; and
A complete driving abstract for five years if the arrest was driving related.
Yes
No
3.
Are you presently under in investigation in any jurisdiction for possible criminal charges? If your answer is
"yes", identify agency and location (street address, city, and state).
A “yes” answer to questions 1 through 3 above will not necessarily bar you from employment.
SECTION IV - FITNESS
Yes
No
1.
Are you able to perform the essential functions of the certificated/classified position(s) for which you have
applied with or without reasonable accommodation?
2.
Do you currently use illegal drugs?
3.
Have you used illegal drugs in the last year? If your answer is “yes”, explain on a separate sheet of paper.
4.
Have you ever been found in any dependency or domestic relations matter to have sexually assaulted or exploited
any minor?
5.
Have you ever been found in any dependency or domestic relations matter to have physically abused any person?
If you answered "yes" to questions 3 or 4, attach copies of any court orders entered in the above proceeding.
DECLARATION
I,
certify (or declare) under the penalty of perjury under
the laws of the State of Washington that the foregoing and all information included in the
application is true and correct.
If the information provided or answer(s) to any question on the application or the eEmployment Background Questionnaire change prior to my being hired, I understand at I must
immediately notify the Ferndale School District.
I understand I must answer this application truthfully and completely. Any falsification or liberate misrepresentation, including omission of a material fact, in completion of this
application can be grounds for denial of employment or continued employment.
Signature
Date
City /State
APPLICANT DISCLOSURE
PURSUANT TO RCW 43.43.834
CHILD AND ADULT ABUSE INFORMATION ACT
Answer YES or NO to each listed item. If the answer is YES to any item, explain in the area provided, indicating the
charge or finding, the date, and the court(s) involved. Within the last seven years:
1.
Have you been convicted of any crimes against children or other persons, as follows: aggravated murder;; first or second degree murder;;
first or second degree kidnapping;; first, second, or third degree assault;; first, second, or third degree rape;; first, second, or third degree
rape of a child;; first or second degree robbery;; first degree arson;; first degree burglary;; first or second degree manslaughter;; first or second
degree extortion;; indecent liberties;; incest;; vehicular homicide;; first degree promoting prostitution;; communication with a minor;; unlawful
imprisonment;; simple assault;; sexual exploitation of minors;; first or second degree criminal mistreatment;; child abuse or neglect as defined
in RCW 26.44.020;; first or second degree custodial interference;; malicious harassment;; first, second, or third degree child molestation;; first
or second degree sexual misconduct with a minor;; patronizing a juvenile prostitute;; child abandonment;; promoting pornography;; selling
or distributing erotic material to a minor;; custodial assault;; violation of child abuse restraining order;; child buying or selling;; prostitution?
ANSWER
IF YES, EXPLAIN BELOW:
2.
Have you been convicted of crimes relating to the financial exploitation if the victim was a vulnerable adult, as follows: first, second, or
third degree extortion;; first, second, or third degree theft;; first or second-degree robbery;; forgery?
ANSWER
3.
Have you been found in any dependency action under RCW 13.34.030(2)(b) to have sexually assaulted or exploited any minor or to have
physically abused any minor?
ANSWER
4.
Have you been found in any domestic relations proceeding under Title 26 RCW to have sexually abused or exploited any minor or to have
physically abused any minor?
ANSWER
5.
Have you been found in any disciplinary board final decision to have sexually or physically abused or exploited any minor or
developmentally disabled person or to have abused or financially exploited any vulnerable adult?
ANSWER
6.
Have you been found in any protection proceeding under chapter 74.3 RCW, to have abused or financially exploited a vulnerable adult?
ANSWER
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.
Applicant Signature:
Witness:
Date:
Place:
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FERNDALE SCHOOL DISTRICT NO. 502
ADMINISTRATIVE PROCEDURES
No. 2314 P-1
Attachment 2
TECHNOLOGY RESOURCES USE AGREEMENT(STAFF)
Staff
Staff at Ferndale School District (FSD) has direct access to the Internet and the FSD network. With this privilege
comes a responsibility. Staff must be informed of the rules regarding Internet and network use and agree to
abide by these rules.
All staff members have a responsibility to monitor student use of computers. If a staff member observes a
student abusing their computer privileges or vandalizing equipment, they should report it immediately to the
appropriate supervisor.
Staff should be aware that downloading or streaming large files such as video or Internet radio uses a significant
amount of our available network bandwidth. This can cause slowdowns district-wide, especially during business
hours (8:00 a.m. - 4:30 p.m.).
Please read this information, sign in the appropriate space below and return to your building office or as
directed.
The following information was extracted from the “Ferndale School District Board Procedure #2314 P-1:
Technology Resources.” Copies of the complete board policy no. 2314 and procedures are available on the FSD
website.
Acceptable Use:
The use of this account must be in support of education and research
Unacceptable Use:
Examples of Activities (but not limited to) which are not permitted:
1. Displaying sexually explicit, pornographic, obscene, lewd or other inappropriate messages or pictures
2. Using obscene language or material
3. Damaging computers, computer system or computer networks
4. Violating copyright laws
5. Using other users’ passwords
6. Trespassing on other users’ systems, folders, work or files
7.
Excessive use of limited resources (beyond time authorized by administrators)
8. Employing the network for commercial, personal, or political purposes.
9. Free “web surfing” during school hours
10. Modifying software on district equipment or installing personal technology on the network without written
permission from Technology Department
11. Accessing any computer not explicitly authorized to use
I understand and will abide by the Technology Resources Use Agreement Policy. I understand that this access is designed
for educational purposes. I recognize that it is impossible for the Ferndale School District to completely restrict access to
offensive, sexually explicit, pornographic or other controversial information and materials available through Internet or other
sources from the network, and I will not hold the school district responsible for information and materials obtained from the
network. I further understand that any violation of the regulations contained therein may result in disciplinary action and
may constitute a criminal offense.
User Name (please print)
Signature
Implemented
Revised
Date
10-12-1995
06-10-2010
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OFFICE OF SUPERINTENDENT OF PUBLIC INSTRUCTION
Office of Professional Practices
Old Capitol Building
PO BOX 47200
Olympia WA 98504-7200
WASHINGTON STATE SEXUAL MISCONDUCT
DISCLOSURE RELEASE
Please print clearly, the School District name, Department and mailing address that this form should be sent to:
The named applicant is under consideration for a position in our district. The Legislature has determined that additional
safeguards are necessary in the hiring of school district employees to ensure the safety of Washington’s school children. The
individual whose name appears below has had previous employment with your organization. As a former employer, we request
you provide the information requested on this form within 20 business days as required by state law (RCW 28A.400). Sexual
misconduct definitions are found in WAC 180-87-080. Your assistance is appreciated.
APPLICANT’S NAME (FIRST, MIDDLE, LAST)
S
E
C
T
I
O
N
FULL NAME WHEN LAST EMPLOYED WITH ORGANIZATION
SOCIAL SECURITY NUMBER
A
APPROXIMATE DATES OF EMPLOYMENT
POSITIONS(S)
I authorize you to release to the school/district listed below, all information related to any acts of sexual misconduct committed by
me as defined by the sate board of education. Such information includes copies of all related documents, including any rebuttal
documents, in personnel, investigative or other files, in accordance with RCW 28A.400. I release the above employer and
employees acting on behalf of the employer from any liability for providing information described in this document.
Applicant Signature
Date
! No record of employment
! Yes, sexual misconduct materials are being forwarded
to requesting school district
! No sexual misconduct materials were found.
!
Former Employer Signature
Title
If yes, Complaint of sexual misconduct was filed with
OSPI:
! Yes ! No
Date
Return all completed information to:
Certificated Personnel
PO Box 698 –
Ferndale, WA 98248
FSD Receipt Date: __________________
Recipient Name: __________________
PO BOX 47200
DISCLOSURE RELEASE
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POSITIONS(S)
Applicant Signature
Date
!
Title
OSPI:
! Yes ! No
Date
PO Box 698 –
Ferndale, WA 98248
FSD Receipt Date: __________________
Recipient Name: __________________
PO BOX 47200
DISCLOSURE RELEASE
S
E
C
T
I
O
N
A
POSITIONS(S)
Applicant Signature
Date
!
Title
OSPI:
! Yes ! No
Date
PO Box 698 –
Ferndale, WA 98248
FSD Receipt Date: __________________
Recipient Name: __________________
CLEAR FORM
RETIREMENT STATUS
Employee Information – To be completed by the employee*
Employee Name (please print)
Social Security Number
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1. Are you retired from one of the Washington State Retirement Systems?
F Yes
2. Are you retired from or have you ever been a member of the Seattle, Spokane or Tacoma F Yes
Employees’ Retirement System?
If yes, which one? ___________________________________
F No
F No
3. Are you currently employed by another public employer and contributing to a
Washington State Retirement System?
F No
Employee Signature
F Yes
Date
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Employer Signature
Date
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Employer Retains Form
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F No
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Ferndale School District #502
6041 Vista Drive
Ferndale
WA
98248
!
!
FERNDALE SCHOOL DISTRICT
AUTHORIZATION AGREEMENT FOR ELECTRONIC PAYROLL DEPOSIT
Employee Name _____________________________________________________
please print
I hereby authorize the Ferndale School District to initiate credit entries and to initiate, if
necessary, debit entries and adjustments for any incorrect credit entries to my account
as directed below. I acknowledge that the origination of ACH transactions to my
account must comply with the provisions of U.S. law.
PRIMARY
Bank Name
SECONDARY
Bank Name
Account Type
Ƒ Checking
Ƒ Savings
Account Number
Account Type
Account Number
Ƒ
Ƒ
Ƒ
Ƒ
Ƒ
Ƒ
Dollar Amount
NET CHECK
(amount after all
other deductions
and secondary
ACH transactions)
Dollar
Amount
Checking
Savings
Checking
Savings
Checking
Savings
This authorization is to remain in full force and effect until the Ferndale School District
has received written notification from me of its termination.
___________________________________________
Signature
____/____/____
Date
Checking Account:
Please attach a VOIDED CHECK for EACH ACCOUNT
(no deposit slips)
Savings Account:
Please attach DEPOSIT SLIP for EACH ACCOUNT
Due in payroll by the 5th of the month in order to be processed with
current month’s payroll.
Y:\Payroll\Direct Deposit Form 2013.doc
Welcome to the Ferndale School District! Please complete the attached form to activate your Employee Access (EA). By using EA \RXQRWRQO\KHOS)HUQGDOH6FKRROV³JRJUHHQ´EXW\RXZLOODOVRKDYHDFFHVVWR\RXU
payroll information 24 hours a day 365 days a year from any computer with internet access. Furthermore, your payroll information is actually available through EA several days before you would have received your paper pay stub. In addition to being able to see your current and past payroll information online, with EA you can do payroll estimates, check your year to date information, look at your W2 or W4 information, and more. For our annual/contracted employees, you can also check your leave activity and leave balances. Please complete the bottom section of this notice to activate your Employee Access. Ferndale School District Employee Access Sign-up Form In order to use Employee Access you will need to have a current email address on file. Please provide the following information. Employee Name _______________________________________________ (Please Print Legibly) Employee Email Address ________________________________________ (Please Print Legibly) I am new to Employee Access. I currently use Employee Access and simply want to change me email address. I currently use Employee Access and need to have my password reset. Employee Signature ____________________________________________ Date ____________________ Please return form to Traci Irvine in the district office. 3RVW2IILFH%R[)HUQGDOH:DVKLQJWRQ-9200
QUESTIONS? Call: Substitute Coordinator Jeanie [email protected] 383-9232 Food Service Applicants Kathy 383-9340 [email protected] Bus Driver Applicants Kori 383-9236 [email protected] Maintenance Applicants Tami 383-9234 [email protected] [email protected] Foreign Language Interpreting Li 383-9400 Sign Language Interpreting Pam 383-9221 [email protected] Tammy 383-9204 [email protected] 383-9202 [email protected] Payroll HR / Personnel Gerri Please contact Jeanie at 383-9232 to set up an appointment to turn in all paperwork. Meetings will take place at the District Office located at 6041 Vista Dr., Ferndale WA.