Your Name *

Applicant's Name *

How are you acquainted? *

How does this applicant relate with others? *

Describe some of this applicant's strengths. *

What are some of this applicant's weak points? *

How does this applicant relate with children/youth? *

Does this applicant have the ability and characteristics to be a good influence on children/youth? *

Has this applicant had substantiated allegations of sexual abuse or sexual harassment, made against them in a prison, jail, lock-up, community confinement facility, juvenile facility, or other institution, including employment with your organization? *

Yes

No

Not that I am aware of

Comments:

Has this applicant been convicted OR civilly or administratively adjudicated, for engaging or attempting to engage in sexual activity in the community facilitated by force, overt or implied threats of force, or coercion, or if the victim did not consent or was unable to consent or refuse? *

Yes

No

Not that I am aware of

Comments:

Has this applicant ever resigned during a pending investigation of an allegation of sexual abuse or sexual harassment? *

Yes

No

Not that I am aware of

Comments:

Submit