Training Certification

District 5100 Youth Protection Policy

Volunteer Training Certification


All volunteers that participate in Rotary Youth Services Programs are required to complete the following certification form. Please print legibly and email to or

fax to: Rotary District 5100 (503) 513-9213

Volunteer’s Name___________________________________________________________


State________ Zip__________________Phone or email____________________________

Rotary Club________________________Club President____________________________

I understand that District 5100’s Youth Protection Policy and Procedures requires that I familiarize myself with the responsibilities of a Youth Services program volunteer. To comply with the certification process I have completed following:

q Attended a club sponsored training on ___________________________________________.

(Date & Location)

q Read and reviewed the materials in Youth Protection Training Kit.

I certify that I, ___________________________________ agree to comply with District 5100’s Youth Protection Policy.


Signature Date

Print Name Date