DIOCESE OF RALEIGH Application for Volunteer Service Occasional Volunteers Name: ___________________________________________________ Address: __________________________________________________ City: ______________________ State: _______ Zip Code: __________ Day phone: ______________________ Cell phone: _________________ Emergency contact: _______________________ Phone: _____________ Work location: ______________________________________________ Has a civil lawsuit or employment complaint ever been filed against you for child or sexual abuse? __________________ If yes, give details: ___________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ Have you ever been convicted of a crime related to child or sexual abuse? _______ If yes, give details: ____________________________________________ _________________________________________________________ _________________________________________________________ Have you ever left an assignment or employment or been removed from an assignment or employment for reasons related to allegations of child abuse, physical abuse, or sexual abuse? __________________ If yes, give details: ___________________________________________ _________________________________________________________ _________________________________________________________ I understand that in signing this Personal Information Sheet, I affirm that the information I have given is true and correct. _____________________________________ _____________ Applicant signature Date |