Previous Street Address
If yes, please explain (attach a separate sheet if necessary). Note: Conviction of a crime that does not involve any risk to children or youth is not an automatic bar to volunteer service.
If yes, please explain (attach a separate sheet if necessary).
(If you prefer, you may discuss your answer in confidence rather than answering it on this form. Answering yes, or failing to answer will not automatically disqualify an applicant.)
Have you ever abused a minor or engaged in conduct including abduction for immoral purposes, sexual assault, failing to secure medical attention for an injured child, pandering, and crimes against nature involving children, taking indecent liberties with children, neglect of children, obscenity offenses, or similar moral impropriety involving children? If yes, please explain (attach a separate sheet if necessary).
If yes, please provide the information on a separate sheet if necessary.
Church Name, Phone Number, Contact Person, Years Attended
Organization Name, Phone Number, Contact Person, Type of Work
Name, Phone Number & Address, Relationship to You
By typing my name below, I acknowledge that this constitutes my electronic signature and that I agree to the terms of this document.
By typing my name below, I acknowledge that this constitutes my electronic signature and that I agree to the terms of this document.