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.  

_____________________________________               _____________

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