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Voluntary Disclosure Statement
If for any reason you would prefer to submit the needed information in a different format please contact Carrie Keuten - carrie@campcare.org
Please list any additional addresses you may have lived at in the last 10 years. And the DATES - From and To that you lived there
(Continue in space provided at the bottom if needed)
2. Have you ever been arrested and/or charged with a crime? (This included all arrest and charges whether or not they were dismissed, deemed nolle prosequi, deferred adjudication, or found not guilty).
3. Have you ever been convicted of any crime relating in any manner to children and/or your conduct with them?
4. 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 fourteen
  • Indecent assault and battery on a mentally challenged person
  • Indecent assault and battery on a person who has obtained the age of fourteen
  • Rape
  • Rape of a child under sixteen 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
5. Have you ever been adjudged liable for civil penalties or damages involving sexual or physical abuse of children?
6. Are you now or have you ever been subject to any court order involving sexual or physical abuse of a minor, including, but not limited to a domestic order or protection?
7. Have your parental rights ever been terminated for reasons involving sexual or physical abuse of children?

I understand that:

a) The camp may deny employment to any person who answers "yes" to any one of question 2-7. If hired and the employer later discovers circumstances that would indicate a "yes" answer to any of the above questions, employment may be terminated immediately.

b) The information provided on this form 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 if that person is found, regardless or when discovered, to:

1. Have a history of complaints of abuse of a minor

2. Have a 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; and/or

3. Have falsified or omitted information in this disclosure statement.

d)This disclosure statement must be updated yearly and immediate notification provided to the camp if any information provided changes.

    State Law Notices Relating to Your Background Report

    Washington State Applicants only: You also have the right to request from the consumer reporting agency a written summary of your rights and remedies under the Washington Fair Credit Reporting Act. 

    California, Minnesota, and Oklahoma Applicants Only: Please inform Camp CARE if you would like a free copy of any REPORT obtained from Sterling Volunteers. Please note you can access your completed report at any time by setting up your profile on the Sterling Volunteers website.

    New York Applicants Only: By signing the authorization, you acknowledge that you have received a copy of New York Correction Law Article 23-A. You have the right, upon written request, to be informed whether an investigative consumer REPORT was requested. If such a REPORT was requested, you will be provided with the name and address of the consumer reporting agency that prepared the REPORT and you can contact that agency to inspect or receive a copy of the REPORT.

    Typing your name below will act as your digital signature.

    By typing my name as my digital signature I understand that Camp CARE, Inc. will recognize that as my legal signature and by checking the box below I give permission to Camp CARE, Inc officials to process a legal background check prior to my acceptance as a staff memeber.
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