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To be completed by every volunteer working with minors.

Name ____________________________

Phone ____________________________

Address  ____________________________

Driver License # ____________________________

State ____________________________

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CHURCH HISTORY AND PRIOR EXPERIENCE ‍

Please list any training, skills or talents that have prepared you to work with minors.

____________________________

Please indicate previous experience working with minors in a church - include places and dates.

____________________________

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Please list previous non-church work involving minors (organization, type of work, and dates).

____________________________

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QUESTIONS

Have you ever been convicted of a criminal offense?  Yes No

Comments: ____________________________

Have you ever been accused or convicted of molesting or physically abusing another person? Yes No

Comments: _____________________________

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BACKGROUND CHECK

I understand that my background check and driving record will be obtained by the church.

APPLICANT’S STATEMENT

The information provided above is correct to the best of my knowledge. I authorize the references, churches or organizations to be contacted regarding my character, fitness and qualifications to work with minors. I have read and agree to abide by these guiding procedures of ____________________________ Church.

Signature ____________________________

Date ____________________________

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VERIFICATION OF INFORMATION

Application reviewed by: ____________________________

Signature ____________________________

Date ____________________________

Church Position ____________________________

Approved: Yes No

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