Application For Children & Youth Workers And Background Information Consent Form printable pdf download

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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Application For Children & Youth Workers And Background Information Consent Form

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