ID ______

WSP_____
EXPO____

THE PIPELINE PROJECT

helping UW undergraduates make a difference in Seattle Public Schools and community organizations

Date: ______________________
Name: ________________________ ________________________ _________________________
(first)

(middle)

(last)

E-mail: _________________________
Birth Date (mm/dd/yyyy): _______/______/______

Gender: _______________________
Student ID #: ___________________

Are you participating in Pipeline as a:

Volunteer
Inner Pipeline student (seminar name and suffix)___________________________________________
Service Learning student (course name & number) ________________________________________
Answer Yes or No to each listed item. If the answer is Yes to any item, please explain in the area provided, indicating the
charge or finding, the date and count(s) involved:
1) Have you been convicted of any crimes against persons?
(Aggravated murder; first or second degree murder; first or second degree kidnapping; first, second or third degree assault; first
second or third degree statutory rape; first or second degree robbery; first degree burglary; first or second degree extortion;
indecent liberties; incest; vehicular homicide; first degree promoting prostitution; communication with a minor; unlawful
imprisonment; simple assault; sexual exploitation of minors; first or second degree criminal mistreatment; child abuse).
Answer ________. If yes, explain below:
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
2) Have you been found in any dependency action under RCW 13.34.030 (2) (b) to have sexually assaulted or exploited any minor
or to have physically abused any minor?
Answer ________. If yes, explain below:
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
3) Have you been found by a court in a domestic relations proceeding under Title 26 RCW to have sexually assaulted or exploited
any minor or to have physically abused any minor?
Answer ________. If yes, explain below:
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
4) Have you been found in any disciplinary board final decision to have sexually abused or exploited any minor or to have
physically abused any minor?
Answer ________. If yes, explain below:
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
I have read the information contained herein and pursuant to RCW 9a.7.2.085, I certify under penalty of perjury under the laws of
the State of Washington that the foregoing is true and correct. I authorize the UW to inquire with former employers or references
from any and all liability in obtaining or disclosing such information. I agree that the UW may, at its discretion, terminate my
volunteer assignment if, among other reasons, I provide misleading or incomplete statements.
*** Signature _________________________________

Date _______________________

Acknowledgement of Risk and Consent for Treatment (for student)

Although the Pipeline Project has taken reasonable steps to refer the student to a safe learning environment with supervisors, it
should be understood this activity is not without risks. In signing this agreement, I acknowledge inherent hazards and risks,
including but not limited to physical injury and death, and I assume those beyond the control of University staff. In case of
emergency, I, the student, give my consent for emergency medical treatment and agree to pay for any charges not covered by my
personal health insurance.
I have read and agree to the agreement, acknowledgment of risk, and guidelines as outlined on the back page.
*** ____________________________
Applicants Signature

Date