Boy State Staff Registration – 2024

Staff:

We are asking for detailed information from you as a staff member of Arizona Boys State. At the National Conference, each state was advised to perform background checks on ALL staff members who are involved in the childres and youth programs. This is to protect Boys State, you, and most of all, the children who participate in the program. Please note that this information is confidential and for Department Headquarters only, and will not be distributed.

Name: *

First

Middle

Last

Mailing Address: *

Address Line 1

Address Line 2

City

State

Zip Code

Is this the same as your physical address? *

Please Chose One!
Yes
No

Physical Address:

Address Line 1

Address Line 2

City

State

Zip Code

Cell Phone: *

Please provide your home phone if you do not have a cell.

Email: *

Email

Confirm Email

Date of Birth: *

Layout

Drivers License State: *

Drivers License Number: *

Vehicle Information (Required for NAU Police Department):

Layout

Make & Model *

State *

License Plate Number *

Color of Vehicle *

Shirt Size: *

Have you moved in the last five years? *

Prior Residence One:

Address Line 1

Address Line 2

City

State

Zip Code

I need to provide an additional residence!

Yes

Prior Residence Two:

Address Line 1

Address Line 2

City

State

Zip Code

I need to provide an additional residence!

Yes

Prior Residence Three:

Address Line 1

Address Line 2

City

State

Zip Code

Have you ever been charged with a crime against a child? *

Please explain:

By signing, I certify the above information is true.

Signature: *

Clear Signature

Boy State Staff Registration – 2024

Please complete this form!

By signing, I certify the above information is true.

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