Voluntary Disclosure Statement

Voluntary Disclosure Statement

Required for all people attending camp 18 years or older.
Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
Date
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
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
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Driver's License Number:
State Issued
Driver's License Expiration Date

MonthDayYear
Date

YesNo
Protecting Children and Youth Training Expiration Date (valid for 3 years from date of completion)

MonthDayYear
Date
YesNo
I understand that:

a) The camp may deny employment or volunteer status to any person who answers “yes” to any of questions 1-5. 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 camp 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
Date

MonthDayYear
Date

”Voluntary Disclosure Statement” form instructions
Every Leader 18 years and older which will attend camp is to fill
out a “Voluntary Disclosure Statement”. Each name must be
screened through the Department of Justice National Sex
Offenders Website, at www.nsopw.gov.

After the name is entered the there is a page that pops up that will
say whether or not there are hits against this name. Print that page
and attach it to the “Voluntary Disclosure Statement” form below.

Some of the names will come back with hits but it will say names
like John Doe and they won't be the same name. Don't worry
about those, just the ones that have names that match exactly are relevant.

The full compilation of “Voluntary Disclosure Statement” forms
must be compiled into a binder kept securely at camp. This binder
needs to be available to county or state inspectors during camp
and the paperwork shredded following camp.

This procedure should be done in a manner as prescribed by your
Stake President.
Upload DOJ Sex Offender search results*

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Certifications

Please add your CPR Card, Lifeguard Certification, Nurses License or any other requirements based on your role at camp.
Click browse files and attach here. You can load more than one doc.

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Should be Empty:

”Voluntary Disclosure Statement” form instructions