Thank you for volunteering to serve at
an Illinois District Youth or Children's event.
Last Name
*
First Name
*
Middle (Enter NMI if none)
*
Address
*
City
*
State
*
Zip
*
Home Phone
Cell Phone
E-mal Address
Event
*
Children's Camp
Youth Camp
District Celebrate Life
Regional Celebrate Life
Spiritual Life Retreat
Other
List event if you checked other above
Social Security Number (Enter N/A if none)
*
Driver's License Number (Enter N/A if none)
*
Drivers license State
Expiration Date
Date of Birth
*
States Lived In Past 5 Years
Crime
*
I have not been convicted of any crime besides a minor traffic violation?
I have been convicted of a crime besides a minor traffic violation?
Crime Explanation
Child Abuse
*
I have never committed physical or sexual abuse against children.
I have committed physical or sexual abuse against children.
Child Abuse 2
I have never been convicted or adjudged liable for civil damages for any action related to children.
I have been convicted or adjudged liable for civil damages for any action related to children.
Consent
*
I consent to a criminal history check & request from any Central Registry of known child abusers.
I refuse a criminal history check & request from any Central Registry of known child abusers.