Circle Leader Application

Street

CityState

Zipcode

If yes to any of these questions, please explain below:

(Background Checks will be a requirement for participating in any activities where children may be present)

*Go to the courthouse and request a free non-certified copy of your background check

Yes, i have read/Had it read and explained to me fully and have agreed to terms and condition of Burke County Circles as above.No, I do not agree to the terms and condition of Burke County Circles as above.

Client Signature Date

Staff Signature Date

Client Information

Employment Information

Best Time To Contact (Check all that apply)

Primary Criteria (Check all that apply)

Family Information (for all members in your household)

Background Information

Additional Information

If yes to any of these questions, please explain below:

(Background Checks will be a requirement for participating in any activities where children may be present)

Person to Notify in Case of Emergency

Agreement and Confidentiality Statement

Burke County Circles Staff Use Only

Thank you for completing this application form and for your interest in Participating with Circles!