Arrest and Conviction Self-Disclosure Form

This form must be completed by summer athletic camp employees or volunteers prior to the start of the camp season. This form captures written reporting of any arrest or conviction for an offense enumerated in the attached "Reportable Offense" list that has occurred since the individual's previous criminal background check.

Completed forms are to be submitted to Mark Williams, Criminal Background Coordinator in the Office of Human Resources. If an individual who is required to complete this form is unsure if his/her arrest or conviction is a reportable offense it is that individual's responsibility to contact the Office of Human Resources for clarification. Failure to disclose a known arrest or conviction may result in disciplinary action up to and including termination. Further, throughout the camp season, individuals must report to Mark Williams any subsequent arrests or convictions within 5 days of knowledge of such arrest or conviction.

Personal Information

Full Legal Name:

Email Address:

Date of Birth:

Summer Camp Name/Sport:

Reportable Offense List

Arrests or convictions for the offenses listed below must be disclosed according to University policy.

Any felony, either listed under Delaware Criminal Code Title 11, or a similar statute in another state, United States territory, or foreign nation, including, but not limited to:

  • Murder
  • Criminal Solicitation
  • Conspiracy
  • Assault
  • Reckless Endangering
  • Vehicular Assault
  • Vehicular Homicide
  • Vehicular Assault
  • Unlawful Imprisonment
  • Kidnapping
  • Interference with Custody
  • Arson
  • Burglary
  • Robbery
  • Theft
  • Receiving Stolen Property
  • Forgery
  • Issue Bad Check
  • Unlawful Use of Credit Card
  • Endangering the Welfare of a Child
  • Hate Crime
  • Stalking
  • Carrying a Concealed Deadly Weapon
  • Possession of a Weapon by a Person Prohibited
  • Possession of a Weapon in a Safe School Zone

Any crime, either misdemeanor or felony, in which the main component of the statute deals with a sexual offense, including those offenses dealing with child pornography.

Any crime, either misdemeanor or felony, dealing with the illegal possession, use, sale, distribution or trafficking of illegal drugs, narcotics, or prescription medications, as listed in Delaware Criminal Code Title 16.

Any misdemeanor where the main component of the crime deals with an act of violence.

Report of Arrest or Conviction

I report that I have been arrested for or convicted of an offense or offenses listed on the "Reportable Offense" list. Listed below are the crimes that I was arrested for or convicted of, the dates of arrest or conviction, and if applicable, the sentence given for the conviction.


Statement of No Reportable Arrest or Conviction

I attest that I have not been arrested for or convicted of an offense or offenses listed on the attached "Reportable Offense" list included with this form, since the date of my last criminal background check for employment.

Signature: Date: