Voluntary Self Disclosure Statement

Applicant must complete all relevant information and sign and date the form.

The following is my true and complete legal name and all information is true and correct to the best of my knowledge:

Full Name*

First NameMiddle NameLast Name

Maiden Name or other name(s) used

First NameMiddle NameLast Name

Email Address*

Phone Number*

Area CodePhone Number

Driver's License #

State

Expiration Date

1) Previous Residence(s) for last 5 years (include college & home residences)

City, State (a)

# Years (a)

City, State (b)

# Years (b)

City, State (c)

# Years (c)

City, State (d)

# Years (d)

City, State (e)

# Years (e)

2) Have you ever been arrested and/or charged with a crime? (This includes all arrest and charges whether or not they were dismissed, deemed nolle prosequi, deferred adjudication, or found not guilty.)*

YesNo

3) Have you ever been convicted of any crime relating in any manner to children and/or your conduct with them?*

YesNo

3) If yes, please explain:

4) 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? *

YesNo

• Indecent assault and battery on a child under fourteen

• Indecent assault and battery on a developmentally delayed/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.

4) If yes, please explain:

5) Have you ever been adjudged liable for civil penalties or damages involving sexual or physical abuse of children?*

YesNo

5) If yes, please explain:

6) Are you now or have you ever been subject to any court order involving neglect, sexual abuse or physical abuse of a minor, including, but not limited to a domestic order of protection?*

YesNo

6) If yes, please explain:

7) Have your parental rights ever been terminated for reasons involving neglect, sexual abuse or physical abuse of children?*

YesNo

7) If yes, please explain:

I release Camp Fire Inland Northwest Council and its agents and any person or entity, which provides information pursuant to this authorization, from any and all liabilities, claims or lawsuits in regards to the information obtained from any and all of the above referenced sources used.

I understand that:

a) Camp Fire Inland Northwest may deny employment to any person who answers "yes" to any one of questions 2-7. If hired and the employer later discovers circumstances that would indicate a "yes" answer to any of the above questions, employment may be terminated immediately.

b) the information provided on this form is subject to verification, which may include a criminal history check run through CampBackgroundChecks.com, National Sex Offenders Public Website and/or request from any Central Registry of child abusers. (A separate release form may be required.)

c) Camp Fire Inland Northwest may terminate employment or volunteer service 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 for seasonal staff or volunteer with a lapse of service and immediate notification provided to Camp Fire Inland Northwest if any information provided changes.

Signature of Applicant / Volunteer*

Date*

MonthDayYear

Signature of Minor's Parent or Guardian

Date

MonthDayYear