Free Declaration in Support - District Court of California - California

{I Case 3:07-cv-02928-JSW Document 30-3 Filed 06/23/2008 Page 1 of 3
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V l X J _ Case 3:07-cv-02928-JSW Document 30-3 “ Filed 06/23/2008 Page 2 of 3
I smite on CALIFORNIA . · namnnvrenr or coiu2ncT1oNs AND Rnm1L1TAT1oN
` RELIGIOUS DIET REQUEST I DISTmUTION_
CD CR 3030 (09/05) - ORlGmAL_ C_lgILE .
I · · oo1=Y — INMATE
E ‘ _ copy - cHA1>LAn»t
I y _ I ·· i _ Gow - OQP.¢Lecn¤¤e>/we F-<>¤b Matopcwgp, I
, HQMATE NAME: att QQ ` FACILITY: C-\ ". G5 ·
it cncn No.: gg ·“t'S?>°k\ I . Housme Ui~uT:_ C-"‘ Wim` . \?> E L` _ ` _
I SIGNATURE: ;, g DATE OF REQUEST: ni ; — been 7, I L-DO 'I l l
I RELIGION: - g _ I RELIGIOUS GROUT (optional).: ‘{\\ués\u§¤ . _ A
l IHAVE BEEN PRACTICING THIS RELIGION . GROUTP ADDRESS: C-T S"` · Q g gxxrrojx _ " V
I ·» U I ' , » g
smcn: \3 ES . _ `
. _ _ ` TELEPHONE N O: _
TM C”m°’“la Depmmint °f · it 0 ams. - g E
- Option 1- Vegetarian meals [including dairy products and eggs) based on regular institution meals. . ·
I -_ Vegetarian protein substitutes are offered when meats are served: Fish may be included.4 U l
• Option 2 - Jewish kosher meals. This program is for Jewish inmates of who wish to follow the
I standards of Judaism. I - . .
4 What_are the religious dietary laws to which you must adhere, and the tenets of your religion? F ,
._ \3‘a§¤.\ msn3rS VM or o¢e&,n$;g2.‘?c><\¤ qyqwéq waanm , QL
e~\e€w~=» ie ’ge$~¤\=’$~¢°<*·">€ ·°~\l¢=*<~®*~°t?»·**‘>‘**“°""°°" i » " \M.., my
. -'be$e’¢<·c»v»X\` we-\, c.¤;,\e;,J;— k,\¤t.;ga.:»\ise\ce · . www .
C n your r`eIi*giousLilietary needs be met by not eating iiorli, and/or following a ve etar'an diet? not, please
explain why. A _ - it ~ - Lg)
` l ` ` Z \\{\· @7, X · `
_i\G\~ ;Omn\t}v\~NSxmL.L S Wév “\ _
‘ . C _ Attaclz documerztzztion to sypport your request (npiiomzb A l
A A INMATES DO NOT WRITE BELOW THIS LINE `
! DIET REQUEST: ‘ I [ I · · I?ROVE _` / A
Ifdenied, give reason(s): ¤ _~.· l I y ‘ _,
Other Action Taken / Comments: _\ ' l
` CHA.PLA.Il;~l’S SIGNATURE: - QE? r;”—4~ ~ ·H i DATE: 3 cn O ‘ · _ »
i l Date Application Received: Date Inmate Interviewed: - A

_, ' Case 3:07-cv-02928-JSW Document 30-3 I Filed 06/23/2008 Page 3 of 3
I STATE OI? CALIFORNIA I DEPAR'l`MEN'l` or CORRECTIONS AND REHABILITATION I
— ‘ .RELIGIOUS DIET PROGRAM AGIREEIVIEN T , DISTRIBUTIOSP
` CDCR 3030-A (09/ 05) I OMGINAL _.C_1§H_E ‘
{ ` COPY—lNlvIA'I*E I . ·
l l COPY- CHAPLAIN
g ’ Gorky _—· Qumran crane POD]; r;1B»·:•Az.—.e'/c ’1-Z
I I would like to participate in the lj jewish Religious Diet Program E! `Religious Vegetarian Diet Prograin (check one).
I understand that in order for me to participate in a Religious Diet Program, foods and preparation practices that are not used for »
general population meals must he used. Therefore, I agree to the following conditions:
_ I1. I understand that I may change my religious diet no more than once each year.
l ` 2. I understand that if I voluntarily request to withdraw from the Religious Diet Program, I must do so in writing
I ·‘ and I must wait for- a period of six months before requesting to be reinstated in the Religious Diet Program.
IQ after six months, I apply to a different Religious Diet Program than the one I previously participated in, my
I request will have to be approved by the Chaplain who oversees that Religious Piet Program. _ ‘
3, I . During meals I will eat and possess on my food tray only those food items served as a part of the Religious Diet
) Program. I understand that a report be kept to verify I am picking up my religious meals. If, for any reason,
I ‘ I am denied any meals under the Religious Diet Program, however, I shall be permitted to eat foods that are not
1 part of the Religious Diet Program and that shall not be deemed to be a violation of this Agreement. I will not_
collect religious food items (other than Canteen items) in my cell and I will follow all CDCR policies and
regulations for dining in my institution. ' ¤ . l ·
4. I may not purchase or consume any food items that are not part of my religious diet. I understand that my
_ Canteen purchases may be routinely monitored. - ·
I 5. Iwill not "double—back" in order to obtain a second meal,.either regular or religious. I I
6. I will consistently pick up my religious diet meals. I understand that a record will be kept indicating when I
pick up my religious meals. `
l .I .
7. · I will not provide all, or portions of my religious meals received through the Religious Diet Program to other
inmates who are not participating in the same Religious Diet Program. ` · _
8. _ I will restrict my diet to religious diet foods. I I · _
I` 9. I understand that should I violate one of these provisions, I will receive one (1) written warning, but be
l ° allowed to continue to participate in the Religious Diet Program. also understand that the Chaplain who
t . oversees my Religious Diet Program shall determine whether I violated any of these provisions.
l 10. I further understand that should I violate any of these provisions aI second time within six (6) months from the I
l date of the first violation, I may be removed from the Religious Diet Program for a period of six (6) months from ‘
l the date of the second violation. I also understand that a— Chaplain shall deterizninewhether I violated any of
these provisions. I also understand that before a·Cha.plain can remove me from the Religious Diet Program, I
shall have the right to confer with a Chaplain regarding the alleged violation(s). . _
l By my signature below, I acknowledge that I have read and discussed the contents of this Agreement with an Institution Chaplain
that oversees this Religious Diet Program. I furdaer agree that if permitted to participate in the Religious Diet Program I will abide _
by the conditions set forth inthis agreement. -
t Inmate Name (print): %§jo;&l¢l{; ;|; · ` I ‘
ax fx I . _
t Inrnate Sign and Date: Q;(;(;@I\ X V g \_° I}?/’ Oil I ·
l Inmate CDCR No.: ‘ S A _ - < A ·
' . · ` _ , , . I
·” Chaplain’s,Name (pnnt): A/?94\ _ gt ?¢’ A
E Chaplain, Sign and Date: - / l _ `
r . I I I

Case 3:07-cv-02928-JSW

Document 30-3

Filed 06/23/2008

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Case 3:07-cv-02928-JSW

Document 30-3

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Case 3:07-cv-02928-JSW

Document 30-3

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