Young Men's Adult Voluntary Disclosure Statement
Full Name
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First Name
Last Name
Date of Birth
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Month
-
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.
Format: (000) 000-0000.
Have you ever been convicted of any crime relating in any manner to children and/or your conduct with them?
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Yes
No
If yes, please explain:
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
If yes, please explain:
Have you ever been adjudged liable for civil penalties or damaged involving sexual or physical abuse of children?
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Yes
No
If yes, please explain:
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
If yes, please explain:
Have your parental rights ever been terminated for reasons involving sexual or physical abuse ofchildren?
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Yes
No
If yes, please explain:
Have you taken Protecting Children and Youth Training? All adults going to camp will be required to take and pass the training.
Yes
No
Protecting Children and Youth Training Expiration Date (valid for 3 years from date of completion)
Have you completed the California mandated LiveScan? All adults going to camp will be required to be fingerprinted.
Yes
No
Do you have a current CPR or Lifeguard certification that will be current during the week of camp?
CPR certified
Lifeguard certified
None
I understand that: a) The camp may deny volunteer status to any person who answers “yes” to any of questions 1-5. 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/or 3) 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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