Voluntary Disclosure Statement

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C.A.M.P.
Constructing Assured and Motivated People
Est. 1956
Directors: David & Janice Brizius
Associate Director: Karen E. Ingram
Program Director: David A. Brizius
Administrator: Tina G. Brizius
Volunteer Disclosure Statement
For All Low & Medium Risk Staff
(Please Print)
Last Name_________________First Name____________Middle Name_______________
Other names by which known(e.g.,maiden name)______________________________
Social Security #____________________Driver’s License#_____________State_______
Home
Address_______________________City__________State___________Zip_____________
Home Phone_______________________Business or Cell Phone____________________
Previous Residence(s) within the last 5 years (include other homes or college)
City___________________________________State____________________When________
City___________________________________State____________________When________
City___________________________________State____________________When________
City___________________________________State____________________When________
City___________________________________State____________________When________
1. Have you had a background/fingerprint check within the past 5 years?
___Yes ___No
If yes, who holds these records?__________________________________________
2. Have you ever been convicted or pleaded guilty to any crime relating in any
manner to children and/or your conduct with them? ___Yes ___No
If yes, please explain_________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
3. Have you ever been convicted or pleaded guilty to any crime listed below?
___Yes ___No
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Failing to provide for a functionally impaired person.
Patient abuse; neglect
Abduction.
Criminal child enticement.
Rape
Sexual battery.
Unlawful sexual conduct with minor.
Page 1 of 2 Volunteer Disclosure Statement
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Importuning.
Voyeurism
Public indecency.
Compelling prostitution.
Disseminating matter harmful to juveniles.
Pandering obscenity and/or pandering obscenity involving a minor.
Illegal use of minor in nudity-oriented material or performance.
Endangering children.
Contributing to unruliness or delinquency of a child.
Corrupting another with drugs or trafficking in drugs
Placing harmful objects in food or confection.
If yes, please explain:__________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
4. Have you ever been adjudged liable for civil penalties or damages involving
sexual or physical abuse of children? ____Yes ____No
If yes, please explain:__________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
5. Are you now or have you ever been subject to any court order involving sexual
or physical abuse of a minor, including a domestic order or protection?
___Yes ___No
If yes, please explain:_____________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
6. If you are a parent, 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:
 Any information I provide on this form is subject to verification.
 The camp may deny my application to volunteer if I answer “yes” to any
of the questions 2-6. If accepted and C.A.M.P. later discovers
circumstances that would indicate a “yes” to those questions, I may be
asked to leave.
 If C.A.M.P. finds that I have falsified any of the information that I have
provided on this form I may be asked to leave.
Signature___________________________________________Date______________________
Printed Signature_______________________________________________________________
Page 2 of 2 Volunteer Disclosure Statement
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