Voluntary Disclosure Statement

Name*

First

Middle

Last

Birth Date*

Home Address*

Street Address

Address Line 2

City

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*

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

State

Years

Address #2

City

State

Years

Address #3

City

State

Years

Address #4

City

State

Years

Address #5

City

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*

Question

Brochure

Virtual Home Visit

Virtual Open House

Question

Brochure

Virtual Home Visit

Virtual Open House

Voluntary Disclosure Statement