Name *

First Name

Last Name

Age Range *

Under 18

18-25

Over 25

Have you at any time ever been arrested for any reason? *

Yes

No

Have you at any time ever been convicted of, or pleaded no contest to, any crime? *

Yes

No

Have you at any time ever engaged in, or been accused of, any child molestation, exploitation or abuse? *

Yes

No

Are you aware of having any traits or tendencies that could pose any threat to children, youth or others? *

Yes

No

Are you aware of any reason why you should not work with children, youth, or others? *

Yes

No

Applicant Verification and Release: I recognize that the organization to which this application is being submitted is relying on the information contained herein. Accordingly, I attest and affirm that all of the information that I have provided is absolutely true and correct. If I answered “yes” to any of the questions above regarding accusations or crimes, I am willing to provide records pertaining to these incidences when asked. I agree to abide by all policies and procedures of the organization, and to protect the health and safety of the children/youth at all times. *

I agree.

Date *

MM

DD

YYYY