Girls Camp Adult Voluntary Disclosure Statement
Full Name
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First Name
Last Name
Other Names (Maiden Name)
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Date of Birth
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Month
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Day
Year
Date
Home Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Drivers License #, State, Expiration Date
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Cell Phone Number
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Please enter a valid phone number.
Previous Residence(s) for the past 5 years- if different from above (include college and home residences)
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Previous Residence (continue on a separate sheet/email if necessary)
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Have you ever been convicted of any crime relating in any manner to children and/or your conduct with them? If yes, explain.
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Yes
No
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 an intellectually disabled 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
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Yes
No
Have you ever been adjudged liable for civil penalties or damaged involving sexual or physical abuse of children?
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Yes
No
Are you now or have you ever been subject to any court order involving sexual or physical abuse or minor, including, but not limited to domestic order or protection?
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Yes
No
Have your parental rights ever been terminated for reasons involving sexual or physical abuse ofchildren?
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Yes
No
I understand that: a) The camp may deny volunteer status to any person who answers “yes” to any of questions 2-6.If camp leadership later discovers circumstances that would indicate a “yes” answer to any of the above questions, service 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 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/or3) have falsified or omitted information in this disclosure statement. d) This disclosure statement must be updated yearly. Name:
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Signature
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