Name:

Campus/Location:

Year in school:

Gender: Select One Male Female

Email Address:

Urban Project Date: Select One May 11-24 Tacoma May 18-31 Portland June 15-29 Tacoma June 15-29 Portland

Ethnicity: Select One White/Caucasian African/Black American Asian Hispanic/Latino Bi/Multiracial Native American International Other

Mailing Address:
Street:
City: State:
Zip:

Important medical information:

Names of any medications being taken or that have been taken in past month:

List any dietary needs:

Allergies or medical conditions staff should be aware of to avoid problems and to assure proper emergency action:

Emergency contact person and phone number:

College or Health Insurance Company name, policy holder, and policy number of policy covering participant:

Background Check: Click here to give permission to InterVarsity Christian Fellowship to obtain a background check.  Note: Under "Ministry" select: Region: Northwest (AK OR WA, Northern ID). (A background check is conducted to protect those we are serving through Summit)

1.  Have you ever been convicted of a criminal offense (felony or misdemeanor, except for minor traffic violations)?

No Yes    You will need to answer “yes” if you have entered into a plea agreement, including a deferred sentence or deferred judgment arrangement, in connection with a criminal charge.  If you have been convicted of such an offense, please attach a statement or explanation including the nature of the offense, date, court where conviction was entered and any other relevant information.  Please attach your statement to the Individual Release Form at the bottom of this page.

2.  Have you ever been charged with a sexual offense, crime of violence or offense relating to children? 

No Yes   If you have been charged with such an offense, please attach a statement or explanation, including name of the offense charged, date, law enforcement agency making the charge and any other relevant information. Please attach your statement to the Individual Release Form.
 

3.  Have you ever been reported to a social services agency, law enforcement authority, child abuse registry or similar organization regarding abuse or misconduct involving children?

No Yes   If so, please provide a description of the circumstances and the name and address of the entity receiving the report.  Please attach the description to the Individual Release Form.
 

4.  Have you ever been subjected to expulsion, reprimand or other discipline by a church, denomination or other religious organization, including InterVarsity? 

No Yes If so, please describe the circumstances and provide the name and address of the church, denomination or religious organization involved.  Please attach the description to the Individual Release Form.
 

5.  Have you ever been dismissed from employment by any employer, including InterVarsity and/or other charitable and religious organizations, following an allegation of sexual misconduct or other immoral or inappropriate behavior or conduct? 

No Yes If so, please describe the circumstances and provide the name and address of the employer.  Please attach the description to the Individual Release Form.
 

6.  Have you ever been the subject of an investigation or allegation of sexual misconduct, sexual harassment or other immoral behavior or conduct involving adults or children?  

No Yes   If so, please describe the circumstances and provide the name and address of the employer, educational institution, church or other organization where the investigation, review or complaint occurred.  Please attach the description to the Individual Release Form.

NOTE: If you checked “yes” to any question above, please provide a complete explanation of the circumstances. If you feel there are any extenuating circumstances, such as your age at the time, please so state. In order to provide a full explanation of an affirmative response, you may attach additional pages to the Individual Release Form. InterVarsity will evaluate what you have written and may ask you to provide additional information. In addition, InterVarsity may determine that it needs to conduct an investigation and may require your assistance with this. This investigation may include a background screening including, but not limited to, the following: National Criminal Database, Social Security Search, National Sex Offenders Registry, and Motor Vehicle Records. While checking “yes” to any of the questions above will not result in automatic disqualification or termination from InterVarsity, InterVarsity may determine that an affirmative response would make an individual unfit for service or association with InterVarsity’s ministry. In all cases, InterVarsity reserves the right to determine, at its discretion, what action should be taken. Please attach your statement/explanation to the Individual Release Form and mail it in to the address below.

If any of your responses or information provided on this form are untruthful or inaccurate, InterVarsity may determine that you are no longer qualified to be associated with the ministry in any capacity.

By signing the Individual Release Form, you agree that, if you become an employee or volunteer of InterVarsity, and become involved in criminal proceedings or other circumstances that would cause your answers to any of the questions above to change, you will immediately notify, and provide a complete description of the circumstances, to the Director of Human Resources of InterVarsity.