BACKGROUND DISCLOSURE

            The Southwest Conference of the United Church of Christ makes every effort to insure that the Conference-sponsored camp and retreat programs are safe environments for children and youth, and the adults who work with children and youth.  As part of our safe practices guidelines, we ask that as an applicant who will work closely with and be responsible for children and youth, that you honestly answer the following questions:

1.      No civil law suit alleging that I attempted or actually engaged in sexual exploitation, misconduct, physical abuse, or child abuse of any kind has ever resulted in a judgment being entered against me, settled out of the court, or dismissed because the statute of limitations has expired.      True_____________   Not True____________

            Comments:

2.      I have never been found guilty, pled guilty or no contest, to criminal charges of sexual abuse, physical abuse, or child abuse.                                                                           True_____________    Not True____________

            Comments:

3.      I have not, within the last 5 years, been found guilty, pled guilty or no contest, to criminal charges relating to the sale or use of controlled substances (including driving while intoxicated and/or driver’s license suspension).

                                                                                          True_____________    Not True____________

            Comments:

4.      In my judgment, there are no facts or circumstances involving me or my background that would warrant further review before my being entrusted with the care and supervision of children and youth during Southwest Conference United Church of Christ Youth and Outdoor Ministry events.       True_____________   Not True_____________

Comments:

5.      I have a valid driver’s license.    True_________ License #_______________________State____        Not True____

      Comments:

6.      I understand that an open exchange of relevant information builds the foundation for healthy relationships. Therefore I authorize all persons related to this application, either as Southwest Conference paid staff, clergy, volunteer leaders, those listed as references, courts and law enforcement, and any other public agencies to respond to inquiries concerning me. They may supply relevant information regarding my background and character relating to this application.  I hereby release them of all liability arising from their responses and comments made in good faith and without malice.

Signature_____________________________________________________________Date____________________

BACKGROUND CRIMINAL AUTHORIZATION FORM:

The Southwest Conference United Church of Christ reserves the right to run and have access to a criminal records check if the need should arise.  Background checks will be run on a regular basis for those adults who have supervisory responsibilities with children and youth.   A “not true” answer on any of the above questions does not automatically deny your participation in the event, but may warrant further exploration.

_____________________________________________          _________________________________________

        Signature                                                                                Print Name

 _____________________________________                                                  ___________________________________________________

                  (Maiden Name – if applicable)                                Signature of Parent or Guardian if applicant is under 18

Social Security No. ______-________-__________     

Date of Birth_______________________________

Place of Birth_______________________________

Print all Aliases:_____________________________

__________________________________________                                                   Date__________________