Girl Scouts of Wisconsin Southeast
Day Camp Adult Background Check

Questions?

Please remember to complete both pages.
Also remember to complete the Adult Day Camp Registration Form.

By completing this form, you are assuring a high quality, safe program for all girls. A component of this program is careful selection and placement of volunteers. Recognizing the vital contribution of volunteers to the Girl Scout Movement, Girl Scouts of Wisconsin Southeast seeks to make participation in the organization personally and professionally rewarding to all volunteers. There shall be no discrimination against an otherwise qualified adult by reason of disability or on the basis of age, race, color, ethnicity, sex, creed, national origin or socioeconomic status. The council will also actively comply with federal, state and local laws and regulations.

Last Name:

First:

Address:

Phone (day):

City:

Phone (eve):

State:

Zip:

Are you 18 years or older?		Yes No
Do you have a valid driver's license?		Yes No State:
Do you have auto liability Insurance?		Yes No
Have you ever volunteered for day camp before with Girl Scouts of Wisconsin Southeast		YesNo

Volunteer positions desired?
At:		(select the service unit listed in the cover of your Day Camp book)

List three individuals not related to you who can describe your qualifications for the positions(s) you listed above:
Name	Phone (day)	Email

1. Do you use illegal drugs? No Yes

2. Have you ever been convicted of a crime? No Yes

3. Are there any current criminal charges pending? No Yes

4. Have you ever been charged with child abuse or neglect? No Yes

5. Has your driver's license ever been suspended or revoked with the last five years? No Yes

6. Are there any other facts or circumstances involving you or your background that would call into
question your being entrusted with the supervision, guidance and of young people or the handling
of finances? No Yes

If you answered yes to any of the previous questions, please explain:

I am familiar with and subscribe, without reservation, to the principles embodied in the Girl Scout Promise and Law. I understand that it is my responsibility as a volunteer to comply with the agreement as stated on the back. I affirm that I have never been convicted of any offense against children. I also consent to the council verifying information included on this application form, including checking references, criminal background checks, and conducting further screening as required by law with the understanding that all this information will be kept confidential by Girl Scouts of Wisconsin Southeastl. I understand that falsification or significant omissions of any information may be considered justification for non-acceptance or dismissal if discovered at a later date. When driving girls, I will have a current, valid driver's license and carry the necessary automobile insurance, or the equivalent, as required by law in the State of Wisconsin or I will not drive anyone involved in a Girl Scout activity. Pending charges or past criminal convictions are not an absolute bar to volunteering with Girl Scouts and those situations will be considered only if there is a substantial relationship to the circumstances of the volunteer position.

Day Camp Code of Conduct Agreement

Families place their trust in Girl Scouting to provide quality leadership and care for participating youth. The opportunity to work with youth is a privileged position of trust that should be held only by those who are willing to demonstrate behaviors that fulfill this trust. For these reasons the following code of conduct is provided for volunteers working at day camp.

As a responsible adult, I agree:

1. To model and subscribe to the following behavior:
    a. Encourage children to feel good about themselves
    b. Provide positive guidance and redirection in matters of discipline, by establishing clear-cut
        limits, and by helping children develop self-control
    c. Promote opportunities that lead to improved self-esteem
    d. Help girls develop a respect for the rights of others
    e. Use appropriate language and wear appropriate clothing
    f. If I smoke, to refrain from smoking when working with girls and smoke only in designated        areas
  g. To treat everyone with courtesy and respect

NOTE: If your attempts to redirect a child's behavior aren't working, please contact the day camp director who can help you determine other appropriate action.

2. To recognize that actions, including the following, which are in any way humiliating or frightening to a child, are unacceptable and should be reported to the day camp director:
    a. Spanking, hitting, shaking, or inflicting any other form of corporal punishment on the child
    b. Verbal abuse, threats or derogatory remarks about the child or their family (this includes                shouting, screaming or purposely embarrassing a child)
    c. Sexual harassment or abuse

3. To carry out activities that promote the following concepts:
    a. Allowing girls to do rather than watch adults complete the tasks/actvities even if it takes longer
    b. Decision making by the girls
    c. Imaginative problem solving
    d. Respect for differences
    e. Respect of and responsibility to the environment

4. To "do my best" to make sure that day camp is a positive experience for everyone- girls and adults. The council is committed to fostering a climate in which relationships are characterized by dignity, respect courtesy and equitable treatment. All adults volunteering at day camp are expected to abide by the Volunteer Personnel Policies and Practices of Girl Scouts of Wisconsin Southeast (located in the health room at camp).

To Part 2