Volunteer Affidavit ⋆ Childrens Clinics in Southern Arizona

Volunteer Affidavit Form

Volunteer Name(Required)

First Last

Volunteer Email(Required)

Today's Date(Required)

Answer the following 2 questions to the broadest extent possible, regardless of how long ago the incident/issue occurred and regardless of whether the incident/issue occurred in Arizona or another state or location.

1. Check one of the following and provide information as directed:(Required)

I have never been convicted of nor am I under investigation for any crimes.

I have been convicted of or am under investigation for a crime. If you checked this box, provide dates, location/ jurisdiction, circumstances and outcome for the crime.

2. Check one of the following:(Required)

I am not required to register as a sex offender

I am required to register as a sex offender

I certify that I understand this affidavit and that my responses are true, accurate, and complete. I understand the failing to disclose information or providing inaccurate information will result in a revocation of my volunteer privileges and could result in further consequences as required by law(Required)

I Agree