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Format: (000) 000-0000.
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- Birthdate *
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- Have you received certification in the following (and is still current)
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- If possible, this year I would prefer my campers to be*
- Preferred volunteer role*
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- Check any/all conditions below that apply/ explain in the space below*
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- Have you ever been convicted of or pleaded guilty to any crimes including municipal, state and federal?*
- Have you ever been placed on probation, received a Suspended Execution, Suspended Sentence orSuspended Imposition of Sentence for any offense involving a minor child (a child under 18), or beenplaced on ANY local, state, or federal sexual registry?*
- Have you ever been sued in a civil court of law where the allegations in the suit involved illegal,inappropriate, or sexual conduct or contact with a minor child?*
- Have you ever been subject to any court order involving any sexual, physical or verbal abuse includingbut not limited to any domestic violence or civil harassment injunction or protective order?*
- Have you ever resigned, been terminated or been asked to resign from a position, whether paid or as avolunteer, due to a complaint(s) of sexual, physical or verbal abuse of minors?*
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- Date
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- Should be Empty: