APPLICATION FOR CHILDREN & YOUTH WORKERS and
BACKGROUND INFORMATION CONSENT FORM
CONFIDENTIAL
Office Use Only
Department: ________________________________
Overseeing Pastor: ___________________________
This application is to be completed by all applicants for any position (volunteer or compensated) involving the
supervision or custody of minors. It is being used to help the church provide a safe and secure environment for
those children and youth who participate in our programs and use our facilities
.
* Identity must be confirmed with a state driver’s license or other photographic identification (attach copy).
Legal Name: ______________________________________________________________________
Last
First
Middle
Maiden Name or other names used: ___________________________________________________
Present Address: ____________________________________________________________________
City: _____________________State: _____________Zip:
How long at present address? ______
Home Phone: _____________ Cell phone: _____________ Email: ____________________________
Former Address: _____________________________________________________________________
City:
State:
Zip:
How long at former address?
If less than 5 years at resident, please provide former counties and states of residence:
Date of Birth:
Place of Birth:
Social Security#:
-
-
Driver’s License#:
State of License Issued:
The above information is required for identification purposes only and is in no manner used as qualification for employment.
The ________________________________Church abides by all applicable state and federal employment laws.
Have you ever been convicted of child abuse or a crime involving actual or attempted sexual molestation of
a minor? YES
NO
If yes, please explain (attach a separate page if necessary): ____________________________________
___________________________________________________________________________________
Were you a victim of abuse or molestation while a minor? YES
NO
UNSURE
If you prefer, you may discuss your answer to this question with the senior pastor rather than answering it on the form. Answering yes,
or leaving the question unanswered, will not automatically disqualify an applicant for work.
Have you ever been convicted of, been accused of or practiced homosexuality? YES
NO
If yes, please explain (Attach a separate page if necessary): _________________________________
_________________________________________________________________________________
Have you ever been convicted of a criminal offense? YES
NO
If yes, please explain
(Attach a separate page if necessary): _____________________________________________________
_________________________________________________________________________________
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