2025 Sunnybrook Worker Disclosure Form

First Name

Last Name

Biological Sex

Birthdate

Email

Phone Number

Have you ever been arrested for any reason?

Yes

No

Have you ever been convicted of, or plead guilty or no contest to any crime?

Yes

No

Have you ever been engaged in or accused of any child molestation, exploitation, or abuse?

Yes

No

Are you aware of having any traits or tendencies that could pose any threat to children, youth or others?

Yes

No

Are you aware of any reason why you should not work with children, youth or others?

Yes

No

If the answer to any of these questions is "yes," please explain in detail. If not, please put Not Applicable.

I recognize that Camp CYOKAMO is relying on the accuracy of the information I provide on the Camp CYOKAMO Worker Disclosure Form. Accordingly, I attest and affirm that the information I have provided is absolutely true and correct.

I do

I authorize the organization to contact any person or entity deemed necessary to collaborate the information provided on this Camp CYOKAMO Worker Disclosure Form, and I further authorize any such person or entity to provide the organization with information, opinions, and impressions relating to my background or qualifications.

I do

I voluntarily release the organization and any such person or entity listed on the Camp CYOKAMO Worker Disclosure Form from liability involving the communication of information relating to my background or qualifications. I further authorize the organization to conduct a criminal background investigation if such a check is deemed necessary.

I do

I have carefully read the policy and procedures of the organization, and I agree to abide by them and to protect the health and safety of the children or youth assigned to my care or supervision at all times.

I do

Signature

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