PRESCHOOL SUBSTITUTE TEACHER DISCLOSURE STATEMENT
PURSUANT TO CHAPTER 43.43 RCW 

ONLY to be completed if you are agreeing to volunteer as a substitute teacher.

Please answer “YES” or “NO” to each listed item. If the answer is YES to any item, explain in the area provided, indicating the charge or finding, the date, and the court(s) involved. The term “convicted” means all adverse dispositions, including a finding of guilt, a plea of guilty or nolo contendere, an Alford plea, stipulation to the facts, a deferred or suspended sentence, or a deferred prosecution.

1. Have you ever been convicted of any crimes against persons as defined in RCW 43.43.830(5) and listed as follows: aggravated murder; first or second degree murder; first or second degree kidnapping; first, second, or third degree assault; first, second, or third degree assault of a child; first, second, or third degree rape; first, second, or third degree rape of a child; first or second degree robbery; first degree arson; first degree burglary; first or second degree manslaughter; first or second degree extortion; indecent liberties; incest; vehicular homicide; first degree promoting prostitution; communication with a minor; unlawful imprisonment; simple assault; sexual exploitation of minors; first or second degree criminal mistreatment; endangerment with a controlled substance; child abuse or neglect as defined in RCW 26.44.020; first or second degree custodial interference; first or second degree custodial sexual misconduct; malicious harassment; first, second, or third degree child molestation; first or second degree sexual misconduct with a minor; patronizing a juvenile prostitute; child abandonment; promoting pornography; selling or distributing erotic material to a minor custodial assault; violation of child abuse restraining order; child buying or selling; prostitution; felony indecent exposure; criminal abandonment; or any of these crimes as they may be renamed?

2. Have you ever been convicted of any crimes relating to financial exploitation as defined in RCW 43.43.830(6) as amended, if the victim was a vulnerable adult and listed as follows: first, second, or third degree extortion; first, second, or third degree theft first or second degree robbery; forgery; or any of these crimes as they may be renamed?

3. Have you ever been convicted of any crime related to drugs as defined in RCW 43.43.830 and listed as follows: manufacture, delivery, or possession with intent to deliver a controlled substance?

4. Have you ever been found in any dependency action under RCW 13.34.040 to have sexually assaulted or exploited any minor or to have physically abused any minor?

5. Have you ever been found by a court in a domestic relations proceeding under Title 26 RCW to have sexually assaulted or exploited any minor or to have physically abused any minor?

6. Have you ever been found in any final disciplinary board decision, or by the director of the department of licensing in the following business or professions (chiropractic, dentistry, dental hygiene, naturopathy, massage, midwifery, osteopathy, physical therapy, physicians, practical nursing, registered nursing, psychology, real estate broker, and salesperson) to have sexually or physically abused any minor or developmentally disabled person or to have abused or financially exploited any vulnerable adult?

7. Have you ever been found by a court in a protection proceeding under Chapter 74.34 RCW to have abused or financially exploited a vulnerable adult?

Pursuant to RCW 9A.72.085, I certify under penalty of perjury under the laws of the State of Washington that the foregoing is true and correct.

I acknowledge that my name will be cross checked against the National Sex Offender Registry.