Voluntary Disclosure Statement

Voluntary Disclosure Statement

Required for all people attending trek 18 years and older
Name*

First NameMiddle NameLast Name
Date of birth*

MonthDayYear
Date
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Other names by which known (Example: maiden name)

First NameMiddle NameLast Name
Other names by which known (Example: maiden name)

First NameMiddle NameLast Name
Phone number 1*
Please enter a valid phone number.Format: (000) 000-0000.
Phone number 2
Format: (000) 000-0000.
Email address (optional)
example@example.com
School or College*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Driver's License #*
State issued*
Expiration Date*

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

CityStateYears
Previous residence 2

CityStateYears
Previous residence 3

CityStateYears
Previous residence 4

CityStateYears
YesNo
If yes, please explain:
3. 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 If yes, please explain:*

YesNo
If yes please explain:
YesNo
If yes, please explain:
YesNo
If yes, please explain:
YesNo
If yes, please explain:
I understand that

1) The trek leader may deny employment or volunteer status to any person who answers "yes" to any of questions 2-6. 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.

c) The trek leader may terminate employment or volunteer services 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.
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty: