Northeastern University 8/28/2014 Ed.
Self-Disclosure Form for Programs Involving Minors
Program Name:_____________________________________________________________________________
Program Date:__________________________
First Name:________________________________________________
Middle Name:______________________________________________
Last Name:________________________________________________
Do you have any other name you have formerly been known by? No Yes
If so, what was it?
Current Address:____________________________________________________________________________
Address Line 2:_______________________________________________________________________
City, State and Zip____________________________________________________________________
Previous Address:__________________________________________________________________________
Address Line 2:______________________________________________________________________
City, State and Zip:___________________________________________________________________
Email Address:__________________________________________________________
Phone:_________________________________
Current Employer:_________________________________________________________________________
Position:___________________________________________________________________________
Have you ever been convicted of, or pled guilty or no contest to a (i) felony, or (ii) a misdemeanor involving
possession of illegal drugs, assault, battery, abuse or sex-related offenses? Please note that a criminal
record search and sex offender record inquiry will be conducted. Although a conviction or arrest is not
necessarily a bar to your service, withdrawal of any offer to participate in a program involving minors.
No Yes
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