Unitarian Universalist Church of Arlington
May, 2004 - April 2005 Adult Reference Form
It is necessary for the Joseph Priestly District to have an accurate record on file for all adults attending District Youth Steering Committee sponsored events. Please read, complete clearly and fully, sign and submit this form  to the address noted below at least two (2) weeks prior to the Con you are attending.

Name: ____________________________________ DOB : ___/___/___ 
Phone Home: (___)___________ Phone Work: (___)___________ Phone Fax: (___)___________
Address: _________________________________________ City: ___________________
State: ______ Zip: ___________ E-Mail: __________________________________
UU Congregation: ___________________________________ # years with current UU Congregation: _____
Experience working with UU youth: _________________________________________________________
_____________________________________________________________________________________
Unique background or related skills: _________________________________________________________
_____________________________________________________________________________________

References
Please list those who are familiar with your character as it relates to work with UU youth.*
1) Reference UU Minister: _________________________________________ Phone: (___)___________
Address: __________________________________________________________________________________
2) Reference DRE: _______________________________________________ Phone: (___)___________
Address: __________________________________________________________________________________
3) Reference YRUU or YAC adult: ___________________________________ Phone: (___)___________
Address: __________________________________________________________________________________
4) Reference Youth: ______________________________________________ Phone: (___)___________
Address: __________________________________________________________________________________

*If not listed in the reference above, we will contact your congregation as well.

Please answer the following questions:
Have you ever been convicted of a criminal offense other then a minor traffic violation? Yes No
_________________________________________________________________________________________
Has any civil action ever been filed against you for sexual misconduct or child abuse? Yes No
_________________________________________________________________________________________
Have you ever resigned, been disciplined or been terminated from employment for reasons
related to sexual misconduct or child abuse? Yes No
_________________________________________________________________________________________
Is there any circumstance involving you or your background that would call into question
your being entrusted with the supervision, guidance or care of youth? Yes No
_________________________________________________________________________________________

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The information on this form is being used to help the Unitarian Universalist Church of Arlington provide a safe and secure environment for youth who participate in Youth Conferences. This information is considered and will be kept confidential. I understand the information I have provided may be verified by contacting persons or organizations listed on this form. The UUCA reserves the right to request a criminal background check be obtained from local police as specified by state law. I hereby release and agree to hold harmless from liability any person or organization that provides information. I also agree to hold harmless the UUCA, its members, trustees, employees and volunteers there of. In signing this application I affirm that the information I have given is true and correct.
Signature: ___________________________________________________ Date: ___/___/___

Please read, complete fully and sign. Return by April 23, 2004.
Send to: RaCon c/o Davi Rios 930 N Arlington Mill Dr. Arlington VA, 22205 Email –RaCon@Davi.Rios.org
Fax – 703 532 7623 Questions or further information, call  703 862 6541