CRIMINAL AND ABUSE DISCLOSURE NOTICE This information is requested by the Naches Valley School District pursuant to Chapter 486, Washington Laws of 1987, and RCW 43.43.700 et.seq. Before permanent employment or engagement of any applicant as an employee or volunteer staff member, the Naches Valley School District will make inquiry to the Washington State Patrol and/or to federal law enforcement agencies regarding any and all matters referred to in this disclosure form. Before receipt of the official response thereto, any employment or engagement will be on a conditional basis only, pending completion of the background investigation and review by the Naches Valley School District. Official records supplied in response to such inquiry will be used by the Naches Valley School District only for making the initial employment or engagement decision. There will be no further dissemination of such records. When such inquiry has been made and official response has been received by Naches Valley School District, you will be notified of the fact of such response at the address and/or phone number supplied by you, within 10 days of such receipt. Thereafter, if you wish to obtain a copy of such response, you may do so at the Administration Office of the Naches Valley School District. 1. Applicant’s full name and date of birth: (First)

Birth Date:

(Middle)

(Last)

(mm/dd/yy)

Any other name(s) applicant has used (including Maiden Name, etc.):

(Sex) –Optional - (Race)

/ (Driver’s Lic. Number/State)

(Social Security Number) - Optional)

2. Applicant’s Address and Phone Number: (Street)

(City)

(State)

(Zip)

(Phone Number)

(Mailing Address, if different) Email Address:__________________________________________________ 3. Volunteer Interests:  Elementary School

 Middle School

 High School

Field Trip ______ Classroom______ Coach______ Library ______ Other: ______ specify__________________________________________________. Please turn over and fill in second page of form For Office Use only: Date Processed: Results:  No Match  Criminal Record  ER  Mr.Lyons (please initial)  Mailed  Hand Delivered  Telephone Call Document cannot be processed without completion of page 2 including signature and date.

4. Have you ever been convicted of any of the following crimes: Aggravated murder, first degree murder, second degree murder, first degree kidnapping, second degree kidnapping, first degree assault, second degree assault, third degree assault, first degree rape, second degree rape, third degree rape, first degree statutory rape, second degree statutory rape, third degree statutory rape, first degree robbery, second degree robbery, first degree arson, first degree burglary, first degree manslaughter, second degree manslaughter, first degree extortion, second degree extortion, indecent liberties, incest, vehicular homicide, first degree promotion prostitution, communication with a minor (for immoral purposes), unlawful imprisonment, simple assault, sexual exploitation of a minor, first degree criminal mistreatment, second degree criminal mistreatment?  Yes  No If yes, give name of each such crime and place and year of conviction: Crime

Place/Year

Crime

Place/Year

5. Have you ever been adjudicated in a civil action (including domestic relations and child dependency), to have physically or sexually abused or exploited any minor?  Yes  No If yes, give the place, year, and court in which such adjudication was made, and the name of the minor:

6. Have you ever been found by a disciplinary board to have physically or sexually abused or exploited any minor?  Yes  No If yes, give place and year of such findings, name of board and name of minor:

Under penalty of perjury, I swear or affirm that, to the best of my knowledge and belief, the information supplied by me in this disclosure is true, accurate and complete.

Dated: Signed: (Applicant)