2015
Protection of Minors Policy
Understanding and Agreement
Personal Information Disclosure
for Returning Authorized Adults Participating in Youth Programs
In my role as an Authorized Adult in a program involving minors, I, ____________________________,
hereby acknowledge my agreement to comply fully with the Protection of Minors Policy, including the
Code of Conduct and all Reporting Obligations set forth in the Policy. I understand it is a requirement of
the policy to disclose the following information:
Program(s) participating in: _____________________________________________
_____________________________________________________________________
Email:
_________________________________________________________
Phone:
_________________________________________________________
1) Have you ever been convicted of, or pled guilty or no contest to, a (i) felony,
or (ii) a misdemeanor involving possession of illegal drugs, assault, battery,
abuse- or sex-related offenses?
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2) Has a verdict or judgment ever been rendered against you in any civil action
arising out of any personal act or conduct related to abuse or sexual abuse of a
child or an adult with special needs?
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3) Has any restraining order, stay-away order or other such order been issued
against you by a court, college or university disciplinary officer, or other authority
in connection with any allegation of verbal or physical abuse, or threat of abuse
or other violence?
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
Yes
No
Yes
No
Yes
No
** If you answered yes to any of the questions above, please explain the nature of the offense or
conduct that formed the basis of the suit, the date, court location, and all other information that would
be helpful to us in considering your application in the space provided below.
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
By signing this form, I certify that the information provided is true and complete. I further agree to
immediately disclose any arrest or conviction occurring while I am serving as an employee or volunteer
in a Boston College program involving minors. I understand that false statements herein, including,
without limitation, any failure to accurately report any arrest or conviction for a Reportable Offense,
shall subject me to disciplinary action, up to and including termination of employment or withdrawal of
any offer to participate in a program involving minors.
Signature: ___________________________________________ Date: _______________________