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Adopt-a-Park or Trail Program - Volunteer Criminal History Information

2. In compliance with RCW 43.43.830-845, volunteers who will have regularly scheduled, unsupervised contact with children under 16 years of age and developmentally disabled persons and/or vulnerable adults as defined in state law will be asked to disclose the following information.
4. Full Legal Name
6. First Name*
7. Middle
8. Last Name*
10. Alias / Maiden Name
12. First Name
13. Middle
14. Last Name
16. Street Address*
18. City*
19. State*
20. Zip*
22. Work Phone
23. Home Phone*
25. Email*
27. Social Security Number*
28. Date of Birth*
    Date of Birth
30. Driver's License Number*
31. State*
32. Expiration Date*
    Expiration Date
34. Have you ever been convicted of any crime against children or other persons, as defined in RCW 43.43.830?*

    1. No
    2. Yes
36. Have you been convicted of crimes relating to financial exploitation where the victim was a vulnerable adult?*

    1. No
    2. Yes
38. Have you been found in any dependency action under RCW 13.34.040 to have sexually assaulted or exploited any minor or to have physically abused any minor?*

    1. No
    2. Yes
40. Have you been found by a court in a domestic relations proceeding under Title 26 RCW to have sexually abused or exploited any minor or to have physically abused any minor?*

    1. No
    2. Yes
42. Have you been found in any disciplinary board final decision to have sexually or physically abused or exploited any minor or developmentally disabled person, or to have abused or financially exploited a vulnerable adult?*

    1. No
    2. Yes
44. Have you been found by a court in a protection proceeding under Chapter 74.34 RCW, to have abused or financially exploited a vulnerable adult?*

    1. No
    2. Yes
46. Answering YES to any of the above inquiries will not necessarily disqualify you from volunteering at the Snoqualmie Parks and Recreation Department, but will require the City of Snoqualmie to make further inquiries before you will be permitted to begin your activities on its behalf. The City of Snoqualmie shall make an inquiry to the Washington State Patrol regarding an applicant's conviction record, disciplinary board final decision, or civil adjudication record. Applicants will be notified of the State Patrol's response within 10 working days of receipt of this information by the City of Snoqualmie. A copy of the response will be available to the applicant.
48. Agreement

    I acknowledge that I have read the entire Notification and Authorization for Background Investigation Disclosure Statement, that I understand the requirements, and I grant permission to the City of Snoqualmie to make inquiry to the Washington State Patrol under the provisions of this law. Pursuant to RCW 9A.72.085, I certify under penalty of perjury under the laws of the State of Washington that the foregoing is true and correct.

    1. I agree.
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50. 1. Receive an email copy of this form.
51. Email address

    This field is not part of the form submission.

52. Submit

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