Voluntary Disclosure Statement (18+)

Full Name*

First Name Last Name

Birth Date*

Month Day Year

Home Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Social Security#

Other names by which known (e.g., maiden name)

Home Phone Number*

Cell Phone Number *

E-mail*

School or College*

School/College Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Drivers License#

State:

Expiration date:

City, State, Years*

City, State, Years

Have you ever been arrested and/or charged with a crime? (This includes all arrest and charges whether or not they were dismissed, deemed nolle prosequi, deferred adjudication, or found not guilty.)*

YesNo

Have you ever been convicted of any crime relating in any manner to children and/or your conduct with them?*

YesNo

If yes, please explain:

Have you ever been convicted of any crime including, but not limited to, those listed below and/or any crime similar in any manner to those listed below? • Indecent assault and battery on a child under fourteen • Indecent assault and battery on a mentally retarded person • Indecent assault and battery on a person who has obtained the age of fourteen • Rape • Rape of a child under sixteen with force • Assault with intent to commit rape • Kidnapping of a child under sixteen with intent to commit rape • Distribution and trafficking of narcotics or other controlled substances • Intent to commit any of the above crimes.*

YesNo

If yes, please explain

Have you ever been adjudged liable for civil penalties or damages involving sexual or physical abuse of children?*

YesNo

If yes, please explain

Are you now or have you ever been subject to any court order involving sexual or physical abuse of a minor, including, but not limited to a domestic order or protection?*

YesNo

If yes, please explain:

Have your parental rights ever been terminated for reasons involving sexual or physical abuse of children?*

YesNo

If yes, please explain

I understand that:
a) The camp may deny employment to any person who answers "yes" to any one of questions 2-7. If hired and the employer later discovers circumstances that would indicate a “yes” answer to any of the above questions, employment may be terminated immediately.
b) The information provided on this form is subject to verification, which may include a criminal history check and request from any Central Registry of child abusers. (A separate release form may be required)
c) The camp may terminate employment or volunteer service of any person if that person is found, regardless of when discovered, to:
1) have a history of complaints of abuse of a minor;
2) have resigned, been terminated, or been asked to resign from a position whether paid or unpaid, due to complaint(s) of sexual abuse of a minor; and/or
3) have falsified or omitted information in this disclosure statement.
d) This disclosure statement must be updated yearly and immediate notification provided to the camp if any information provided changes.

Signature*

Date*

Signature of Minor’s Parent or Guardian

Date

Voluntary Disclosure Statement (18+)

1. Previous residence(s) for last five years (include college and home residences):

2.

3.

4.

5.

6.

7.