Camp Fire USA builds caring, confident youth and future leaders.
ORTH CETRAL WASHIGTO COUCIL
CAMP FIRE VOLUNTEER APPLICATION
Last Name: _________________________First Name:__________________________ Today’s Date:________
Positions Applying For: *Club Leader( ), * Assist Club Leader( ), **Board Member( ), **Associate Board( ).
*Best Day For Your Weekly Club Meeting: _________, Times:__________, Town/ Location:_____________.
Home Phone: _____________________, Cell: ___________________, Email: ________________________.
Street Address:_____________________, City:__________________________, State:____, ZIP:___________.
School Now Attending Or Present Occupation: ____________________________________________________.
Languages You Speak: English ( ), Spanish ( ), Other_____________________________________________.
Responses to the three below questions are used for certain grants or other funding applications: (Optional)
Gender: Female____, Male____.
Age: Under 35___, 35-60___, Over 60___
Ethnicity: Black___, White__, Hispanic__, Asian__, Native American__, Other________________________.
REFERECES: Non-relatives References will be contacted about your character, experience and ability.
Name
City/State
Phone
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)
(
)
(
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PO BOX 1734 • WENATCHEE, WA 98807-1734
(509) 663-1609, [email protected]
Ninos y Familia--Primero y siempre / Children and families--first and always
WASHIGTO STATE PATROL
AD
ORTH CETRAL WASHIGTO COUCIL
VOLUNTEER BACKGROUND CHECK
Answer each question. If the answer is YES, explain the charge or finding, the date and the court(s) involved.
1. Have you ever been convicted of any crimes against persons as defined in Section 1 of Chapter 486, Law of
1987, listed as follows: murder, kidnapping, statutory rape, robbery, arson, burglary, manslaughter, extortion,
indecent liberties, incest, vehicular homicide, promoting prostitution, communication with a minor, unlawful
imprisonment, assault, sexual exploitation of minors, criminal mistreatment? ASWER: Y( ) o ( )
EXPLAI:________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
2. Have you ever been found in any dependency action under RCW 13.34.030(2)(b) to have sexually assaulted
or exploited any minor or to have physically abused any minor? ASWER: Y( ) o ( )
EXPLAI: _______________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
3. Have you ever been found by a court in a domestic relations proceeding under Title 26 RCW to have
sexually abused or exploited any minor or to have physically abused any minor? ASWER: Y( ) o ( )
EXPLAI:________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
4. Have you ever been found in any disciplinary board final decision to have sexually abused or exploited any
minor or to have physically abused any minor? ASWER: Y( ) o ( )
5. EXPLAI:_____________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Child/Adult Abuse Record Search background checks will be conducted on all employees and volunteers who
will have access to children through the Washington State Patrol [Revised Code of Washington (RCW)
43.43.830-43.43.845]
Social Security Number:______________________, Possess a current Drivers License ANSWER: Y( ) No ( )
Pursuant to RCW 9A.72.085, I certify under penalty of perjury under the laws of the State of Washington that
the forgoing is true and correct.
Volunteer’s Signature: _______________________________________________________