YOUTH INITIATIVE VOLUNTEER APPLICATION

APPENDIX A2
YOUTH INITIATIVE VOLUNTEER APPLICATION
PLEASE RESPOND TO THE QUESTIONS BELOW BY PLACING AN "X" IN THE YES/NO COLUMN

PLEASE RESPOND TO THE QUESTIONS BELOW BY PLACING AN "X" IN THE YES/NO COLUMN

Rows	YES	NO
1 . Are you at least 18 years of age?
2. Are you willing to attend a training course about Delta’s policies and procedures governing its youth initiatives and to keep current on updated policies?
3. Do you agree to complete the background screening procedure which includes a face-to-face interview, reference checks, and a criminal background check?
4. Have you ever been charged with, or convicted of any crime, including any misdemeanor or felony? If so, check “Yes” and provide details in section below. For each instance, provide the following information: (a) the relevant charges; (b) relevant dates; (c) identify the court(s) in which any proceedings were held; (d) supply the disposition related to all charges (e.g., acquittal; conviction; no contest; charges currently pending, etc.); (e) list the punishment that was issued related to any convictions
5. Have you ever been investigated by state or federal authorities for child abuse or neglect? If so, provide details in section below, including: (a) reason for investigation; (b) relevant dates; (c) relationship to child/children involved; (d) the agency or agencies that conducted the investigation; (e) the court(s) in which any proceedings were held; (f) results of investigation; (g) any punishment or other requirements imposed by the relevant authorities
6. Have you ever been treated (outpatient or inpatient treatment) for any mental illness, psychiatric condition, or drug or alcohol addiction? If so, explain in section below, and provide applicable dates of treatment or hospitalization.
7. Have you ever been terminated from a paid or volunteer position? If so, explain in section below.
8. Other than the above, is there any fact or circumstance involving you or your background that would call into question your being entrusted with the supervision, guidance, or care of young people? If so, explain in section below.

Provide explanations below (attach additional sheets as necessary and reference the applicable question number).
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APPENDIX A2 (cont'd)YOUTH INITIATIVE VOLUNTEER APPLICATION
I. SCREENING PROCEDURE
It is the policy of Delta Sigma Theta Sorority, Incorporated ("Delta") that each potential volunteer for any of its youth initiatives programs be screened by the Chapter. As part of the screening process, you are required to:
1. Complete this written application.
2. Consent to background screening, which includes: (1) state and/or federal criminal background checks and (2) search of state and federal sex offender registries.
3. Provide two personal references and two professional references.
4. Copy of driver's license or state issued identification.
5. Complete a personal interview.
6. Notify the Chapter immediately if convicted of an offense at any time after submitting this application.
II. PERSONAL INFORMATION
Name

First NameMiddle InitialLast Name
Previous last names (maiden, previous married, etc.):
List any aliases or other names used:
Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Current Driver's License No.
State:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone: (Home)
Format: (000) 000-0000.
(Cell)
Format: (000) 000-0000.
(Work)
Format: (000) 000-0000.
Email:
example@example.com
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APPENDIX A2 (cont'd)YOUTH INITIATIVE VOLUNTEER APPLICATION
III. CRIMINAL BACKGROUND CHECK FEE REQUIREMENT
In order to ensure that our youth initiative programs are conducted in a safe environment, all volunteers and parents or guardians who have direct contact with youth on multiple occasions must complete Delta's FULL volunteer screening process, including an online criminal background check. The background check must be conducted by a vendor selected by Delta and the volunteer/parent or guardian is responsible for payment of the background fee. The criminal background check fees average between $35 - $130 and are non-refundable. The chapter will provide the necessary information to access the online vendor selected by Delta.
IV. INFORMATION RELEASE
I, ___________________________________ hereby authorize the local Chapter of Delta Sigma Theta Sorority, Incorporated (the "Chapter") to conduct background screening related to my application for a volunteer position with the Chapter's youth initiative programs.

First NameLast Name
The Chapter's background screening procedures include the review of local, state, and nationwide criminal background checks, the search of state and federal sex offender and child abuse registries and other databases, and communication with personal and professional references.

I authorize the Chapter to obtain information necessary to complete its background screening procedures to be obtained from any relevant source, including federal, state, and local law enforcement agencies; searchable online official registries and databases; and individuals I have identified as personal and professional references.

I also authorize the Chapter to complete background screening on me on a triennial basis (every 3 years) for as long as I remain a volunteer if I am accepted as a volunteer and serve for more than one year. I further agree to complete all requirements to facilitate the Chapter's completion of such background screening.
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APPENDIX A2 (cont'd)
YOUTH INITIATIVE VOLUNTEER APPLICATION
I also agree that once accepted as a volunteer, I must notify the Chapter immediately if I am the subject of any pending charges and/or convicted of an offense at any time after submitting this application or being cleared as a volunteer.
I also further acknowledge that a volunteer with pending charges relating to abuse, neglect, a drug related offense, any crime with the involvement of youth, termination from a paid or volunteer position related to misconduct with a youth, any crime involving violence or recent history of substance abuse, will be terminated as a volunteer.
I certify under penalty of perjury that the foregoing is true and correct.
Signature:
Name:

First NameLast Name
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
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APPENDIX A2 (cont'd)
YOUTH INITIATIVE VOLUNTEER APPLICATION
V. REFERENCES
Please list the names, addresses, and phone numbers of four people you would like to use as character references (only people you have known for at least one year). Any information Delta Sigma Theta Sorority, Incorporated gathers from these references will be treated confidentially and will not be released to you, the applicant.
Reference 1:
Name:

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone:
Format: (000) 000-0000.
Cell Phone:
Format: (000) 000-0000.
Email:
example@example.com
Relationship:
How long known:
Reference 2:
Name:

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone:
Format: (000) 000-0000.
Cell Phone:
Format: (000) 000-0000.
Email:
example@example.com
Relationship:
How long known:
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APPENDIX A2 (cont'd)
YOUTH INITIATIVE VOLUNTEER APPLICATION
Reference 3:
Name:

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone:
Format: (000) 000-0000.
Cell Phone:
Format: (000) 000-0000.
Email:
example@example.com
Relationship:
How long known:
Reference 4:
Name:

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone:
Format: (000) 000-0000.
Cell Phone:
Format: (000) 000-0000.
Email:
example@example.com
Relationship:
How long known:
Should be Empty:

APPENDIX A2

YOUTH INITIATIVE VOLUNTEER APPLICATION

APPENDIX A2 (cont'd)YOUTH INITIATIVE VOLUNTEER APPLICATION

I. SCREENING PROCEDURE

II. PERSONAL INFORMATION

APPENDIX A2 (cont'd)YOUTH INITIATIVE VOLUNTEER APPLICATION

III. CRIMINAL BACKGROUND CHECK FEE REQUIREMENT

IV. INFORMATION RELEASE

APPENDIX A2 (cont'd)

YOUTH INITIATIVE VOLUNTEER APPLICATION

APPENDIX A2 (cont'd)

YOUTH INITIATIVE VOLUNTEER APPLICATION

V. REFERENCES

Reference 1:

Reference 2:

APPENDIX A2 (cont'd)

YOUTH INITIATIVE VOLUNTEER APPLICATION

Reference 3:

Reference 4: