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Volunteer Screening Form
Child Abuse & Criminal Background Information
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* Indicates required question
Email
*
Your email
Full Name (First, Middle, Last) (alias ex. maiden)
*
Your answer
Birth Date
*
MM
/
DD
/
YYYY
Social Security # [not required but helpful]
Your answer
Phone Number
*
Your answer
Current Address & Zip Code
*
Your answer
List ALL Prior Addresses Since 1975
*
Your answer
List Every Household Member since 1975 & their relationship to you - along with their gender & age. * Parents/Guardians must be listed.
*
Your answer
Have you lived in the state of PA for 10 years consecutively?
*
Yes
No
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