2025-2026 NAC Youth Initiative Volunteer Forms Package

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:

a.     Complete this written application.

b.     Consent to background screening, which includes: (1) state and/or federal criminal background checks and (2) search of state and federal sex offender registries.

c.     Provide two personal references and two professional references.

d.     Copy of driver’s license or state issued identification.

e.     Complete a personal interview.

f.      Notify the Chapter immediately if convicted of an offense at any time after submitting this application.
III. PERSONAL INFORMATION
Name*

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

MonthDayYear
Date
Current Driver's License No.:*
State:*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone (Home)
Please enter a valid phone number.
Phone (Cell)*
Please enter a valid phone number.
Phone (Work)
Please enter a valid phone number.
Volunteer’s Email*
example@example.com
(Continued on next page)

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.
III. INFORMATION RELEASE
I blanks* , hereby authorize the local Chapter of Delta Sigma Theta Sorority, Inc ("Chapter") to conduct background screening related to my application for a volunteer position with the Chapter's youth initiative programs. The Chapter's background screening procedures include the review of local, state, and nationwide criminal background checks, search of state and federal sex offenders and child abuse registries and other database 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.
If you received the results from your background screening please upload them here.

If you are still waiting, you can email your results to riskmgmt@norfolkdst.org.
Cancelof
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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*

Clear
Printed Name:*
Dated*

MonthDayYear
Date

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 Number*
Please enter a valid phone number.
Cell Phone Number*
Please enter a valid phone number.
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 Number*
Please enter a valid phone number.
Cell Phone Number*
Please enter a valid phone number.
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 Number*
Please enter a valid phone number.
Cell Phone Number*
Please enter a valid phone number.
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 Number*
Please enter a valid phone number.
Cell Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Relationship:*
How long known:*

Appendix A8

DELTA YOUTH INITIATIVES CODE OF ETHICS
All members and any Delta staff working with participants in Delta’s youth initiatives are expected to observe a code of ethics. This Code of Ethics embodies the affirmation of your commitment to follow tenets that are integral to Delta’s youth initiatives. Please initial each statement below:
Initials
I will treat youth with respect, care, and acceptance. I know that all young people are valuable and capable of helping others and improving their communities. I will use a democratic approach when working with youth.
Initials
I will honor my volunteer commitment. I will strive to live up to my volunteer commitment by working the hours necessary to fulfill the volunteer role I have accepted.
Initials
I will seek training for my volunteer role. I will participate in meetings, self‐study, or other training opportunities, which will help me work more effectively with youth and adults.
Initials
I will provide a safe environment. I will not harm youth or adults in any way, whether through sexual harassment, physical force, verbal or mental abuse, neglect, or other harmful activities.
Initials
I will abstain from using alcohol or any illegal substance while working with or while responsible for youth; neither will I allow youth to use any such substance while under my supervision. For states where substances, such as marijuana, are legal, I will abstain from use while working with or while responsible for youth.
Initials
I will obey the laws of the locality, state, and nation.
Initials
I will strive to be a positive role model. By my example, I will help youth learn to respect and cooperate with others. I will teach others to compete honestly and fairly.
Initials
I will work as a “team player” for the good of all persons. I will work cooperatively with other adult volunteers for the good of all involved in the youth initiatives.
Initials
I will work within the Delta Sigma Theta Sorority system. As a volunteer, I am accountable for my actions. If my personal conduct is deemed to be in violation of any of Delta’s policies, I understand I may be relieved of my volunteer role.
Initials
I will not have unsanctioned outside contact with any youth participant; without the expressed written permission from the parent/guardian or the parent/guardian is physically present during the outside contact.
Signature

Clear

APPPENDIX A8 (cont'd)

MANDATORY REPORTING POLICY
It is the policy of Delta Sigma Theta Sorority, Incorporated (“Delta”) that all staff, members, and any participant in the youth initiatives must immediately report any suspected child abuse and/or neglect of program participants or other incidents involving program participants. All such suspected reports must be made to appropriate state and/or local authorities, and to the Chapter President. The Chapter President shall notify the Regional Director immediately of all allegations of abuse and or neglect or other incidents involving program participants. Delta staff and all volunteers must follow their state’s mandatory reporting of child abuse and neglect procedures.

To report child abuse or neglect, contact Child Help USA at 1‐800‐422 4453. For the most current information on State Child Abuse And Neglect Reporting Numbers and a list of reporting agencies and phone numbers organized by state, refer to the National Organizations section of Child Welfare Information Gateway at https://www.childwelfare.gov/organizations/.
Initials
I agree to follow all Youth Initiatives Program guidelines and understand that any violation shall result in suspension and/or termination of the volunteer relationship.
Initials
I understand that the Delta Youth Initiatives Program is not obligated to provide a reason for its decision in accepting or rejecting me as a volunteer.
Initials
I understand that to be considered, I must return all the following completed items, along with this application, and that any incomplete information will result in the delay in processing of my application:
- Copy of valid driver's license
- Signed Youth Initiative Volunteer Application, which includes an information Release and References.
I understand that my signature below authorizes submission of the information in this application for child abuse and neglect and criminal records checks, including sexual offenses, if deemed necessary. In addition, by signing, I certify that all information provided herein is correct, and I agree with and will adhere to Delta’s Code of Ethics and Mandatory Reporting Policy as printed above.

Please read this carefully before signing.
Signature*

Clear
Name*

First NameLast Name
Date*

MonthDayYear
Date

APPENDIX A11

ANNUAL CONFIRMATION OF YOUTH VOLUNTEER STATUS AND INFORMATION UPDATE
I understand it is the policy of Delta Sigma Theta Sorority, Inc. that volunteers in Delta’s youth activities must undergo background screening every three years to remain a volunteer. In the years that a background check is not required, I understand that I must confirm that my personal information has not changed from the prior year. If any information has changed, I understand that I must provide the updated information.

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.
Updated Information: Any changes to my name, address, phone, email, driver’s license, or state issued identification number is listed in the box below. I have also listed in the box below any pending charges and/or convictions of a criminal offense against me since being cleared as a volunteer.*
Initials
Please initial your confirmation of the following:

I have no updated information or any pending charges and/or convictions of a criminal offense against me since being cleared as a volunteer from the prior year.
Signature*

Clear
Name*

First NameLast Name
Date*

MonthDayYear
Date
Year of Initial Volunteer Application*
Should be Empty:

APPENDIX A2

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III. PERSONAL INFORMATION

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Appendix A8

APPPENDIX A8 (cont'd)

APPENDIX A11