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Name_________________________________Birth
Name:_______________________
Social Security#:____________________ Birth date:____________
Age________
Driver's License #:____________ State_________ Expiration
Date__/___/___
1. Residence(s) for last 5 years (including college and home
residences):
Full Address______________________________________________Years_______
Full Address______________________________________________Years_______
Full Address______________________________________________Years_______
(Continue on separate sheet if necessary)
2. Have you ever been convicted of any crime
relating in any manner to children and/or your conduct with
them?_______ If yes please explain: (Continue on separate sheet if
necessary.)
_____________________________________________________________________
_____________________________________________________________________
3. 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?_______
*Indecent assault and battery on a child under 14
*Indecent assault and battery on a
mentally retarded person
*Indecent assault and battery on a
person who has obtained the age of 14
*Rape
*Rape of a child under 16 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: (Continue on separate sheet if necessary.)
_____________________________________________________________________
_____________________________________________________________________
4. Have you ever been adjudged liable for civil penalties or damages
involving sexual or physical abuse of children?_______ If yes, please
explain: (Continue on separate sheet if necessary.)
_____________________________________________________________________
_____________________________________________________________________
5. Are you now or have you ever been subjected to any court involving
sexual or physical abuse of a minor, including, but not limited to a
domestic order or protection?_______If yes, please explain: (Continue
on separate sheet if necessary.)
_____________________________________________________________________
_____________________________________________________________________
6. Have your parental rights ever been terminated for reasons
involving sexual abuse of children?_______If yes, please explain:
(Continue on separate sheet if necessary.)
_____________________________________________________________________
_____________________________________________________________________
I understand that:
a. The camp may deny emloyment to any person who answers questions
numbered 2-5 above in the affirmative.
b. In applying for a camp position the information, which I have
furnished, on this form and my counselor application is subject to
verification, which may include a criminal history check and request
from any Central Registry of child abusers.
c. The camp may terminate employment or volunteer service of any
person:
1.) found to have a history of complaints of abuse of a
minor and/or
2.) found to 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.
d. This disclosure statement must be updated yearly.
Signature____________________________________Date:_____/_____/20__
Signature of Minor's Parent/Guardian_____________________________
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