Voluntary Disclosure Statement

Return directly to the HopeWood Connect Day Camp congregation you will be serving. Return this form to church: Address:Contact:

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

(Continue on separate sheet if necessary)

Have you ever been convicted of any crime relating of any manner to children and/or your conduct with them? yes If yes, please explain (Use a separate sheet, if necessary)

Have your 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? (yes or no)

• Indecent assault and battery on a child under fourteen
• Indecent assault and battery on a mentally handicapped 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 and/or other controlled substances
• Intent to commit any of the above crimes

Have you ever been adjudged liable for civil penalties or damages involving sexual or physical abuse of children? no yes If yes, please explain (Use a separate sheet, if necessary.)

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? If yes, please explain (Use a separate sheet, if necessary).

Have your parental rights ever been terminated for reasons involving sexual or physical abuse of children? yes If yes, please explain (Use a separate sheet, if necessary).

I understand that:

a. The camp may deny employment or volunteer service to any person who answers "yes" to any one 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 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 and signed annually.