Summer Staff or Work Crew (circle one)

Property ________________________
Month __________________________

VOLUNTEER BACKGROUND QUESTIONNAIRE

FOR SUMMER STAFF AND WORK CREW
Young Life has always been about loving kids for Christs sake. But in todays society our responsibility also includes protecting
kids in some new ways. Major organizations that work with kids are all moving toward more stringent screening of staff and
volunteers, and we feel we must do the same. Thank you for your cooperation in filling out the following questionnaire.
yes

no

1. Have you ever been convicted of a crime of violence?*

If you have been convicted of such an offense, please attach a statement or explanation, including nature of
offense, date, court where conviction was entered and any other relevant information.

yes

no

2. Have you ever been convicted of a sexual offense or offense relating to children?*
If so, please attach a statement or explanation, including nature of offense, date, court where conviction was
entered and any other relevant information.

yes

no

3. Have you ever been the subject of an investigation or allegation of sexual misconduct, sexual harassment or
other immoral behavior or conduct involving adults or children?
If so, please describe the circumstances and provide the name and address of the employer, educational
institution, church or other organization where the investigation, review or complaint occurred.

*If you live in Colorado, Illinois, Ohio, Oklahoma or Washington (state), you need not disclose criminal convictions that are contained in sealed or
expunged records.

If you marked yes to any questions above, we ask that you provide a complete explanation of the circumstances. If you feel there
are any extenuating circumstances, such as your age at the time, please let us know. Young Life will evaluate your written
explanation and may ask you to provide additional information. In addition, Young Life may determine that it needs to conduct an
investigation and may require your assistance with this. While checking yes to any of the questions above will not result in
automatic disqualification from Young Life, Young Life may determine that an affirmative response would make an individual unfit
for service or association with Young Lifes ministry. In all cases, Young Life reserves the right to determine, at its discretion, what
action should be taken.
If any of your responses or information provided on this form are untruthful or inaccurate, Young Life may determine that you are
no longer qualified to be associated with the ministry in any capacity.

I understand that Young Life takes the issues of sexual misconduct and sexual harassment very seriously, and I believe with Young
Life that it is critical to the mission and ministry that Young Life staff and volunteers conform to the highest standards of sexual
morality and conduct. I realize that failure to comply with the conduct outlined in Young Lifes Sexual Misconduct Policy and
Sexual Harassment Policy could result in disciplinary action and/or immediate discharge from this summer assignment at a Young
Life property.
I authorize Young Life, in its discretion, to conduct a background check, which may include contacting previous employers,
educational institutions, churches and other organizations with which I may have been involved, as well as a check of records of
criminal arrests and civil judgments involving sexual assault, child abuse and molestation, sexual harassment, incidents of violence
and other unlawful conduct.

________________________________
Signature

________________________________
Printed Name

____________
Date

____________________
Phone
YL-1023 (Aug 02) Printed in U.S.A.