Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

If youth, please provide your parent's phone number.

(###)

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Volunteer Name(First, Middle, Last) *

First Name

Last Name

Have you been convicted of ANY of the above, including any of these crimes as they may have been renamed? *

-Custodial Assault -First, Second, or Third Degree Assault of a Child -First, Second, or Third Degree Assault -Simple Assault -First or Second Degree Custodial Interference -Incest -First, Second, or Third Degree Rape of a Child -Child Abandonment -Child Abuse or Neglect as Defined in RCW 26.44.020 -Violation of a Child Abuse Restraining Order -Child Buying or Selling -First or Second Degree Custodial Sexual Misconduct -First, Second, or Third Degree Child Molestation -First or Second Degree Sexual Misconduct with Minor(s) -Patronizing a Juvenile Prostitute -Selling or Distributing Erotic Material to Minor(s) -Sexual Exploitation of Minor(s) -Communication with a Minor for Immoral Purposes -First Degree Arson -First Degree Burglary -Voyeurism -Aggravated Murder -First or Second Degree Murder -First or Second Degree Extortion -First or Second Degree Kidnapping -First or Second Degree Manslaughter -First, Second, or Third Degree Rape -First or Second Degree Robbery -Indecent Liberties -Felony Indecent Liberties -Felony Indecent Exposure -Misdemeanor Indecent Exposure -Vehicular Homicide -Unlawful Imprisonment -Malicious Harassment -Criminal Abandonment -First or Second Degree Criminal Mistreatment -Promoting Pornography -First Degree Promoting Pornography -Prostitution

Yes

No

Check any of the following if you have ever been convicted of these crimes relating to financial exploitation where the victim was a vulnerable adult (defined as adults of any age who lack the functional , mental, or physical ability to care for themselves).

First, Second, or Third Degree Extortion

First, Second, or Third Degree Theft

First, Second, or Third Degree Robbery

Forgery

Any of the foregoing crimes as they have been renamed

Have you ever been convicted of any crime involving the manufacture, delivery, or possession with the intent to manufacture or deliver a controlled substance? *

Yes

No

Have you ever been found in any dependency action under RCW 13.34.040 to have sexually assaulted or exploited any minor or to have physically abused a minor? *

Yes

No

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? *

Yes

No

Have you ever been found in any disciplinary board final decision to have sexually or physically abused any minor or develop-mentally disabled person, or to have abused or financially exploited any vulnerable adult? ("Disciplinary board final decision" means (a) any final decision by the director of the Department of Licensing for real estate brokers and salesperson or (b) any final decision by a disciplinary authority under Chapter 18.130 RCW of the secretary of the Department of Health for the following business of Professionals: chiropractic, dentistry, dental hygiene, naturopathy, massage, midwife, osteopathic medicine and surgery, physical therapy, physicians, practical nursing, registered nursing and psychology). *

Yes

No

Have you ever been found by a court in a protection proceeding under Chapter 74.34 RCW and have abused or financially exploited a vulnerable adult? *

Yes

No

Are you presently charged with , but not convicted of, any of the crimes or offenses described in Questions 1-7 above? *

Yes

No

Please type full name to serve as signature. *

First Name

Last Name

Date *

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DD

YYYY