SEACAMP Voluntary Disclosure Statement

Employee Information

Full Name

Date of Birth

Other Names You Have Been Known By

Provide Full Name (first, middle, last)

Current Address

Street Name

Apartment/Unit Number

City

State/Province

Zip/Postal

Country

Past Residence Locations for Last Five Years

All residences including college and home residences. Only applicable if different from current City and State.

City, State, Years of Residence

None, if not applicable

City, State, Years of Residence

Disclosure

Have you ever been arrested and/or charged with a crime? Include all arrests and charges whether or not they were dismissed, deemed nolle prosequi, deferred adjudication, or found not guilty.

Yes

Please explain

Signature

Electronic Signature Consent

I Accept - by selecting “I Accept,” you are signing this Agreement electronically. You acknowledge you have read and understand the above terms, and you agree your electronic signature is the legal equivalent of your manual/handwritten signature on this Agreement. By selecting "I Accept" using any device, means or action, you consent to the legally binding terms and conditions of this Agreement. You further agree that your signature on this document (hereafter referred to as your "E-Signature") is as valid as if you signed the document in writing.

By signing, I understand

The information provided is complete and true. SEACAMP San Diego may deny employment to any person who answers "Yes" to the disclosure question or later discovers circumstances that would indicate a "Yes" answer. The information provided on this form is subject to verification, including a criminal history check and request from any Central Registry of child abusers. SEACAMP San Diego may terminate employment of any person if that person is found to have a history of complaints of abuse of a minor, have resigned or been terminated from a position due to complaint(s) of sexual abuse of a minor, and/or have falsified or omitted information in this disclosure statement. This disclosure statement must be updated yearly and immediate notification provided to the camp if any information provided changes.

First Name

Last Name

Signature

Clear

Date of E-Signature

04/13/2026

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