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Thank you for an amazing COVID-free summer!
Click here to learn more about the 2021 season
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ASK A
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Virtual Home Visit
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About
Why Camp Sequoia?
Mission & Approach
Who We Serve
Our Team
Facilities
Virtual Tour
Health & Safety
Dining Services
FAQs
Alumni
What’s New
Programs
Summer Camp
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Voluntary Disclosure Statement
Name
*
First
Middle
Last
Birth Date
*
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
4
5
6
7
8
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10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2022
2021
2020
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2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
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1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Home Address
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
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Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
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Montana
Nebraska
Nevada
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New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Social Security Number
*
Please format with dashes: Ex. 123-45-6789
Other Names You're Known By
Ex. Maiden Name
Phone
*
Other Phone
optional
Email
*
School or College (If Applicable)
*
Do you have a state-issued driver's license?
*
No US driver's license
I can legally drive in the United States
Driver's License Number
*
State Where License Was Acquired
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
Date License Expires
*
MM
DD
YYYY
Please list previous residence(s) for the last five years (include college and home residences):
Address #1
*
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
Years
Address #2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
Years
Address #3
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
Years
Address #4
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
Years
Address #5
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
Years
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.)
Yes
No
If yes, please explain:
*
Have you ever been convicted of any crime relating in any manner to children and/or your conduct with them?
*
Yes
No
If yes, please explain:
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?
*
Yes
No
• Indecent assault and battery on a child under fourteen
• Indecent assault and battery on a mentally retarded 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.
If yes, please explain:
Have you ever been adjudged liable for civil penalties or damages involving sexual or physical abuse of children?
*
Yes
No
If yes, please explain:
Are you now or have you ever been subject to any court order involving sexual or physical abuse of a minor, including, but not limited to a domestic order or protection?
*
Yes
No
If yes, please explain:
Have your parental rights ever been terminated for reasons involving sexual or physical abuse of children?
*
Yes
No
If yes, please explain:
I understand that:
a) The camp 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
and request from any Central Registry of child abusers. (A separate release form may be required)
c) The camp may terminate employment or volunteer service of any person if that person is found, regardless
of when discovered, to:
-have a history of complaints of abuse of a minor;
-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
-have falsified or omitted information in this disclosure statement.
d) This disclosure statement must be updated yearly and immediate notification provided to the camp if any information provided changes.
Signature
*
Date
*
Date Format: MM slash DD slash YYYY