• Rotary District 5050 — USA Background Check and Criminal Records Check Consent Form

    All volunteers and each host family members age 18 or older must separately complete this form.

  • Rotary International and District 5050 strive to create and maintain a safe environment for all youth who participate in Rotary activities. To the best of their ability, Rotarians, Rotarians’ spouses and partners, and other volunteers must safeguard the children and young people they come into contact with and protect them from physical, sexual, and emotional abuse.

  • Personal Information

  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Are you a Rotarian?

  • General Questions

  • 1. Have you ever been convicted of a crime?*
  • 2. Have you ever had findings made against you in any civil adjudicative proceeding that resulted in a finding of, or upheld an agency finding of, domestic violence, abuse, sexual abuse, neglect, abandonment, violation of a professional licensing standard regarding a child or vulnerable adult, or exploitation or financial exploitation of a child or vulnerable adult uner any provision of law?*
  • 3. Have you ever been convicted of or pled guilty to or been subject to any court order involving any sexual, physical, verbal or emotional abuse including but not limited to a domestic violence or civil protection order or injunction?*

  • Waiver, Consent and Release

  • I declare under penalty of perjury of the laws of the state of Washington that the following is true and correct:

    I am of legal age, am competent to make this declaration, and do so based upon personal knowledge.

    All of the statements in this application, and any attachments hereto, are true and correct to the best of my knowledge.  

    I have not withheld any information that would affect this declaration unfavorably, if disclosed.  

    I understand that any omission or facts or misrepresentation will result in my elimination from consideration for any volunteer position with Rotary District 5050’s youth programs or its affiliates.  

    I understand that District 5050’s intent is to deny a position in its youth programs to any person who has admitted to, been convicted of, or otherwise found to have engaged in sexual or physical abuse or harassment.  

  • I understand that automatically disqualifying criminal convictions include:

    • Any felony (American) or Indictable Offense (Canadian) that involves assault, threats, sexual offending, or domestic violence;
    • Any felony or Indictable Offense that has occurred within the prior ten years;
    • Any other criminal conviction for crimes involving assault, threats, sexual offending, or domestic violence;
    • Any offense involving driving or being in physical control of a vehicle when under the influence of alcohol and/or drugs when the volunteer would be responsible for transportation of youth.

  • I understand that other convictions/findings not specifically enumerated herein may also disqualify an applicant depending on the age of the conviction, the nature of the conviction, and whether the applicant has remained crime-free for at least ten years in the community.

  • I hereby give my permission for District 5050 to investigate, verify, and obtain information given in this declaration, including searches of law enforcement and published records, criminal background and reference interviews. I understand that this information will be used, in part, to determine my eligibility to become an approved youth programs volunteer in Rotary District 5050. I also understand that as long as I remain a Rotary District 5050 youth programs volunteer, the criminal history check may be repeated at any time and will be repeated annually until such time that I revoke this consent or discontinue my volunteer activities.

  • I understand that I will have an opportunity to review the criminal history and that there is a procedure available for clarification if I dispute the record as received.  

    I specifically acknowledge that District 5050 may inquire about, and I authorize them to verify, my employment experience, personal references, background, including criminal records checks (which may contain arrest and conviction data).  I waive any right to assert that such an investigation or request constitutes and invasion of my privacy.  I recognize that such inquiries are in the interest of all persons involved in Rotary District 5050’s youth programs and I fully consent to such investigations.  

  • IN CONSIDERATION of my acceptance into and participation as a District 5050 youth programs approved volunteer, I, to the full extent permitted by law, hereby release and agree to save, hold harmless and indemnify all members, officers, directors, committee members, and employees of Rotary District 5050, its clubs and Rotary International (Indemnitees) from any and all liability, loss, property damage, personal injury, or death, including such liability which may arise out of the negligence of any of the Indemnitees , which may be suffered or claimed by me as a result of an investigation of my background in connection with this declaration.

  • I further agree to conform to the rules, regulations, and policies of Rotary International, District 5050’s youth programs and its affiliates, and understand that my service can be modified or terminated, with or without notice or cause, at any time, at the option of either District 5050’s Youth Services Chair, or at my option. I understand and agree that that District 5050’s youth programs or their affiliates may, in their sole discretion, decline to accept my application for volunteer services, with or without cause.

  • I acknowledge that I have read and understand the above Waiver, Consent, and Release, and that I sign this form voluntarily. 

    I further acknowledge that if I execute this document with a digital signature that it has and shall have the same force and effect as if I had personally signed the document with a pen.  

  • Date Signed*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: