Confidential Screening Form

KELLY GREEN GLOBAL: CONFIDENTIAL SCREENING FORM
If you have participated in a Kelly Green Global ministry mission trip in the past five years and have completed this form for KGG, you do not have to complete it again. However, if it has been more than five years since you completed this form, please complete and return.
For Workers with Preschool, Children or Youth and Short Term Missions

James 3:1 states that “Not many of you should presume to be teachers, my brothers, because you know that we who teach will be judged more strictly.”

The purpose of this form is to allow Kelly Green Global to effectively recruit workers for ministry events and trips in which KGG participates, with the understanding that those in leadership will be judged by others and must be above reproach. In order to assure the children’s safety and protect the ministry from harm, we ask every worker or volunteeer with preschoolers, children, or youth to complete this form.

This form is to be completed by all mission team participants which involves the supervision or custody of minors and is being used to help our organization provide a safe and secure environment for children and youth who participate in our ministry programs.
PERSONAL INFORMATION
Today's Date:*

MonthDayYear
Social Security #:*
Date of Birth:*

MonthDayYear
Race:*
Sex:*

MaleFemale
Full Name*

First NameMiddle NameLast Name
Have you been known by any other name? (including maiden name, name change, etc.) *

YesNo
If yes, please list:
Current Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
How long have you lived at current address?*
Home Phone Number:*

Area CodePhone Number
Business Phone Number:*

Area CodePhone Number
Cell Phone Number:*

Area CodePhone Number
Previous Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
How long did you live at this address?*
Do you have a current Driver’s License? *

YesNo
If yes, list Drivers License Number & State where issued:
If No, please explain.:
Have you ever been the subject of an investigation or inquiry involving physical, mental or sexual abuse?(If yes, please provide an explanation in next text area).*

YesNo
Explanation of investigation.:*
Have you ever been physically, mentally or sexually abused?:*

YesNo
If yes, did you receive counseling?:*

YesNo
Are you now involved in pornography in any shape, form or fashion?:*

YesNo
If yes, please explain:*
(By not answering the above questions, or answering yes to the above questions, it is our understanding that you agree to speak with Pastor Kelly Green.)

Have you made a profession of faith in Jesus Christ?*

YesNo
If yes, when?:
Are you a church member?*

YesNo
If yes, please list your church's name."
List all your previous church work which involved preschool, children and/or youth (please list each church’s name with city and state as well as the type of work you performed, along with dates):*
List all previous NON-church work which involved preschool, children and/or youth (list each organization name with city and state as well as the type of work you performed, along with dates):*
Please list any gifts, training, education or other factors that have prepared you for preschool, children, or youth work.*
1st Personal Reference: (not employers or relatives):*

First NameLast Name
1st Reference Email:*
1st Reference Phone Number:*

Area CodePhone Number
2nd Personal Reference: (not employers or relatives):

First NameLast Name
2nd Reference Email:
2nd Reference Phone Number:

Area CodePhone Number
The information I have provided on this application is correct to the best of my knowledge. I authorize any reference or church provided in this application to give you any information (including opinions) that they may have regarding my character and fitness for work with preschool, children or youth. In consideration of the receipt and evaluation of this form by Kelly Green Global (KGG), I hereby release any individual, church or organization, including record custodians, both collectively and individually, from any and all liability for damages of whatever kind or nature which may at any time result to me, my heirs, or family, on account of compliance or any attempts to comply with this authorization. I further authorize a representative of KGG to do initial and subsequent random criminal background checks and abuse registry checks. I further state that I HAVE CAREFULLY READ THE FOREGOING RELEASE AND KNOW THE CONTENTS THEREOF AND I SIGN THIS RELEASE AS MY OWN FREE ACT. This is a legally binding agreement, which I have read and understand.

MEMORANDUM OF UNDERSTANDING REGARDING CONFIDENTIALITY OF CHILD CARE MEDICAL INFORMATION

The purpose of this memorandum of understanding is to emphasize that any medical information which is covered by confidentiality requirements pursuant to the State of Florida or any Federal Statute or Law, including but not limited to, sexually transmitted diseases or tuberculosis, disclosed to or obtained by the undersigned volunteer from KGG, or its agents, shall be held in strict confidence and shall not be disclosed to any individual or entity.
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KELLY GREEN GLOBAL: CONFIDENTIAL SCREENING FORM

PERSONAL INFORMATION

MEMORANDUM OF UNDERSTANDING REGARDING CONFIDENTIALITY OF CHILD CARE MEDICAL INFORMATION