Volunteer Screening Form
Child Abuse & Criminal Background Information
Email address *
Full Name (First, Middle, Last) (alias ex. maiden) *
Birth Date *
MM
/
DD
/
YYYY
Social Security # [not required but helpful]
Phone Number *
Current Address & Zip Code *
List ALL Prior Addresses Since 1975 *
List Every Household Member since 1975 & their relationship to you - along with their gender & age. * Parents/Guardians must be listed. *
Have you lived in the state of PA for 10 years consecutively? *
A copy of your responses will be emailed to the address you provided.
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