Kiwanis Club of Bradenton,- Christmas in August

Bradenton Kiwanis - Christmas in August McKechnie Field August 6th 7:00 AM to 1:00 PM (Event 533 9th Street West August 5th 9:00 AM - 2:00 PM (setup) Bradenton, Florida Volunteer Registration: Contact Information - Please print clearly

Name(s)______

Street Address______

City ST ZIP Code ______

Home Phone______Cell Phone______

E-Mail Address______

Club/Organization Affiliation- ______

Will you need community service hours? Yes___ No ___ Club Advisor:

Availability: During which hours are you available for volunteer assignments?______

Because we work with children, we must ask you to please provide the following information. Please respond even if you do not anticipate volunteering directly with children at the present time. Please answer this section with YES or NO. If YES, please explain.

A. Are you the subject of an indicated child abuse or maltreatment report on file in any state? If yes, please provide date(s), description(s) and explanation of incident(s). Attach additional sheets if necessary.

______

B. Have you ever been terminated, suspended, or placed on probation, reprimanded or otherwise penalized by an employer for child abuse/ or maltreatment in this state or elsewhere? If yes, please provide date(s), description(s) and explanation of incident(s). Attach additional sheets if necessary.

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C. Have you ever been convicted of a violent crime, child abuse or neglect, child pornography, child abduction, kidnapping, rape or sexual offense or ever been ordered by a court to receive psychiatric or psychological treatment in connection therewith? If yes, please provide date(s), description(s) and explanation of incident(s). Attach additional sheets if necessary.

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I declare that all the statements I have made in this screening summary are true, correct and complete to the best of my knowledge.

Signature:______Date: ______

Printed Name: ______

Complete form and return to Bradenton Kiwanis: PO BOX 1250 Bradenton, Florida 34206 Or email form to: Christy Cardillo at [email protected]