Convicted of any crime against children or other persons (aggravated murder, first or second degree murder; first or second degree kidnapping, first, second or third degree assault: first, second or third degree assault of a child: first, second or third degree rape; first second or third degree rape of a child; first or second degree robbery, first degree arson; first degree burglary; first or second degree manslaughter; first or second degree extortion; indecent liberties; incest; vehicular homicide; first degree promoting prostitution, communication with a minor; unlawful imprisonment; simple assault; sexual exploitation of minors; first or second degree criminal mistreatment; child abuse or neglect as defined in RCW 26,44.020: first or second degree custodial interference; malicious harassment; first, second or third degree child molestation; first or second degree sexual misconduct with a minor; patronizing a juvenile prostitute; child abandonment; promoting pornography; sell or distributing erotic material to a minor; custodial assault; violation of child abuse restraining order; child buying or selling; prostitution; felony indecent exposure; or any of these crimes as they may be renamed in the future?)

Found in any dependency action or by a court in a domestic relations proceeding or in any disciplinary board final decision to have physically or sexually assaulted, exploited or abused any minors?

Released from prison?

Convicted of any offense that involved drugs/alcohol?

Convicted of any felony other than those listed in part A in Washington or any other state?

I certify under the punishment of perjury under the state of Washington that the statements above are true and correct. I understand that this offer to volunteer with Tri-County Partners: Habitat for Humanity is contingent upon an acceptable response from the Washington State Patrol and/or federal law enforcement agency, whose criminal history review will be sought of all applicants upon application and as necessary thereafter. I agree that Tri-County Partners Habitat for Humanity may, at its discretion, preclude me from volunteer service, if, among other reasons, I provide misleading or incomplete statements. I hereby grant permission for Habitat for Humanity to conduct a criminal background check and sex offender registry check.

I have read and understood all safety requirements outlined in the Work Crew Safety Guidelines. Please keep the Guidelines document for future reference.