WASHINGTON STATE PATROL FORM

Your name *

Email address *

Birthdate *

Gender *

Alias/Madian Name (if applicable)

Where are you serving/ Interested in serving? *

DISCLOSURE STATEMENT:

Champions Centre takes reasonable steps to provide for a safe and secure environment throughout our locations for its Members, Attendees, Visitors, Children and Youth.

Champions Centre requires that a WSP disclosure be filled out and that a background check be submitted to the State Patrol prior to involvement in various areas of the church.

I authorize Champions Centre to run my WSP annually prior to the expiration. *

Have you ever been convicted of the following crimes:

Convicted of any crimes against children or other persons? *

Convicted of crimes relating to financial exploitation if the victim was a vulnerable adult? *

Convicted of crimes related to drugs as defined in RCW 453.43.830? *

Found in any dependency action under RCW 13:34.040 to have sexually assaulted or exploited any minor or to have physically abused a minor? *

Found by the court in a domestic relations proceeding under Title 26 RCW to have sexually abused or exploited any minor to have physically abused any minor? *

Found in any disciplinary board final decision to have sexually or physically abused or exploited any minor or developmentally disabled person or to have abused or financiallyexploited any vulnerable adult? *

Found by a court in protection proceeding under Chapter 74.34, to have abused or financially exploited a vulnerable adult? *

I swear or affirm that the information provided above is true and complete and contains no willful misrepresentation of the facts. *

Type your Full name:

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