WAIVER OF CONFIDENTIALITY
AND
CONSENT TO RELEASE INFORMATION
RELATED TO EMPLOYMENT EVALUATIONS
TO:
Chief School Administrator or Designee
(Name of prior employing School District)
FROM:
(Applicant’s Name)
In recognition of the need for information on the part of the Red Mesa Unified School District in order to evaluate my application for
employment with that District, I hereby waive to the following extent the protection of confidentiality, whether provided by law,
bylaw, policy, or contract provision, which may pertain to the evaluation of my performance as an employee of your School District.
You are authorized to release to the Red Mesa Unified School District copies of documents concerning me and to discuss any
information concerning me with the Red Mesa Unified School District, so long as the documents and information are related to:
1.
2.
3.
The prior employing School District certificated employees’ evaluation system,
any other evaluation system used by your District, or
matters contained in files maintained by my supervisor or by the personnel department, or other similar division, of the
prior employing School District.
This waiver of confidentiality and consent to release information does not extend to the following:
Dated this
day of
Applicant’s Signature:
Red Mesa Unified School District
Personnel Department
HC 61 Box 40
Teec Nos Pos, AZ 86514
(928) 656-4100 FAX (928) 656-4106
,
.
RED MESA UNIFIED SCHOOL DISTRICT
HC 61 BOX 40
Teec Nos Pos, AZ 86514
Telephone: (520) 656-4100
Fax: (520) 656-4106
Web: http://www.redmesa.k12.az.us
EQUAL EMPLOYMENT OPPORTUNITY SURVEY
NAME:
LAST
FIRST
M.I.
SOCIAL SECURITY
NUMBER
TO ALL APPLICANTS:
We consider all applicants for positions without regard to race, color, religion, sex, national origin, citizenship, age, mental
or physical disabilities, veteran/reserve/national guard or any other similarly protected status. We also comply with all
applicable laws governing employment practices and do not discriminate on the basis of any unlawful criteria.
This survey is to be completed by applicant on a voluntary basis. Not for interview purposes.
APPLYING FOR:
RACE, ETHNICITY, AND GENDER INFORMATION
FEMALE
American Indian/Native American/Polynesian ......................
Asian or Micronesian .............................................................
African-American ...................................................................
Hispanic ..................................................................................
White ......................................................................................
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MALE
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DEFINITIONS OF RACIAL/ETHNIC GROUPS
The racial/ethnic groups for State affirmative action programs and federal reporting purposes are defined as follows:
AMERICAN INDIAN:
Any person having origins from the indigenous people of North America (including Alaska and
the Polynesian Islands), and who maintains cultural identification through tribal affiliation or
community recognition.
ASIAN:
Any person having origins in any of the original peoples of the Far East, Southeast Asia, or the
Indian Subcontinent. This area includes China, Japan, Korea, and the Philippine Islands.
AFRICAN-AMERICAN: (not of Hispanic origin); any person having origins in any of the Black racial groups of Africa.
HISPANIC:
Any person of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish
culture or origin, regardless of race.
WHITE:
(not of Hispanic origin); any person having origins in any of the original peoples of Europe,
North Africa, or the Middle East.
PLEASE RETURN WITH APPLICATION