District Protection Policy 5100 Youth
Youth Volunteer Affidavit
Complete and Fax to (503) 513-9213
District 5100 is committed to creating and maintaining the safest possible environment for all participants in Rotary activities. It is the duty of all Rotarians, Rotarians’ spouses, partners, and any other volunteers to safeguard to the best of their ability the welfare of and to prevent the physical, sexual, or emotional abuse of children and young people with whom they come into contact.
PERSONAL INFORMATION
Name:_______________________________________________
Address:_____________________________________________
City:__________________State:__________ Zip/Postal Code:_______
E-mail______________________________ Fax:___________________________________________
HomePhone:__________________________ Business Phone:_____________
How long at this address?____ (If less than five years, please list prior residence(s) on the back of this sheet)
Government identification(e.g.Social Security Number)______________________
Date of Birth:________________________________
Are you a member of a Rotary Club? Yes____________ No___________
If yes, please give club name and year joined________________________________
Position applied for:__________________________________________________
Have you held a Youth Service Program position in the past? Yes_____________ No ______________
If yes, what position and when? ______________________________________
Employment History ( 5 years – please attach additional sheets, if necessary )
Current Employer:_________________________________________________________________________
Address/City/State/Zip_____________________________________________________________________
Telephone:___________________________ Position: ______________________
How Long with this company?_____ Supervisor’s name______________________
VOLUNTEER HISTORY WITH YOUTH ( 5 years – attach additional sheets, if necessary )
Organization Name:_______________________________________________________________________
Address/City/State/Zip_____________________________________________________________________
Telephone:_______________ Position ___________________________________
Dates Held:______________ Director’s Name:_____________________________
Previous Organization:_____________________________________________________________________
Address/City/State/Zip_____________________________________________________________________
Telephone:__________ Position________________________________________
Dates Held:___________ Director’s Name_______________________________
PERSONAL REFERENCES (not relatives and not more than one former or current Rotarian)
- Name: _______________________Telephone:________________
Address/City/State/Zip:_______________________________________________________________
Relationship:________________________________________________________________________
- Name:__________________________________ Telephone:_______________________________
Address/City/State/Zip_________________________________________________________________
Relationship:_________________________________________________________________________
- Name:__________________________________ Telephone:_______________________________
Address/City/State/Zip:________________________________________________________________
Relationship:_________________________________________________________________________
QUALIFICATIONS AND TRAINING
What qualifications and/or training do you have to Youth Service Program or this position? Please describe in full. _______________________________________
CRIMINAL HISTORY
1. Have you ever been convicted of or plead guilty to any crime(s)? Yes__ No __
Have you ever been subject to any court order involving any sexual, physical or verbal abuse including but not limited to any domestic violence or civil harassment injunction or protective order? Yes __ No __
If yes, describe in full. Also indicate date(s) of crime(s) and in which country and state each took place. (Attach a separate sheet if needed)
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
WAIVER/CONSENT/RELEASE
I certify that all of the statements in this affidavit, and in any attachments hereto, are true and correct to the best of my knowledge. I also certify that I have not withheld any information that would affect this affidavit unfavorably, if disclosed. I understand that any omission of facts or misrepresentation will result in my elimination from consideration for any volunteer position with the District 5100 Youth Service Program or its affiliates. I further certify that I understand that District 5100 Youth Service Program’s intent is to deny a position to anyone convicted of a crime of violence or a crime against another person.
I hereby give my permission for District 5100 to investigate, verify and obtain information given in this affidavit, including searches of law enforcement and published records (including driving records and criminal background checks), contact with former employees and reference interviews. I understand that this information will be used, in part, to determine my eligibility for a volunteer position with District 5100 Youth Service Program. I also understand that as long as I remain a volunteer here, the criminal history records check may be repeated at any time. I understand that I will have an opportunity to review the criminal history and that there is a procedure available for clarification, if I dispute the record as received.
I specifically acknowledge that the District 5100 Youth Service Program or its affiliates will inquire about, and I authorize them to verify, my prior employment, experience, personal references, background, including criminal background checks which may contain arrest and conviction data. I waive my right to assert that such an investigation or request constitutes an invasion of my privacy. I recognize that such inquiries are in the interest of all persons involved the District 5100 Youth Service Program, and I fully consent to such investigations.
IN CONSIDERATION of my acceptance and participation in the Youth Service Program, I, to the full extent permitted by law, hereby release and agree to save, hold harmless and indemnify, all members, officers, directors, committee members and employees of the participating Rotary Clubs and Districts, and of Rotary International (“Indemnities”), from any or all liability for any loss, property damage, personal injury or death, including any such liability which may arise out of the negligence of any of the Indemnities, which may be suffered or claimed by me as a result of an investigation of my background in connection with this affidavit.
I further agree to conform to the rules, regulations, and policies of Rotary International, the District 5100 Youth Service Program and its affiliates, and understand that my service can be modified or terminated, with or without notice or cause, at any time, at the option of either the District 5100 Youth Service Program or its affiliates, or at my option. I understand and agree that the District 5100 Youth Service Program or its affiliates may, in their sole discretion, decline to accept my application for volunteer services with or without cause.
I ACKNOWLEDGE THAT I HAVE READ AND UNDERSTAND THE ABOVE AFFIDAVIT, WAIVER, CONSENT AND RELEASE, AND THAT I SIGN THIS FORM VOLUNTARILY
Date: _______________
Please Print Name________________________
Signature_______________________________
John Howell
