Employee and Volunteer Ministry Application Form

This application form is to be completed by all employees and those desiring a volunteer ministry position involving the supervision or custody of children and/or youth. This form will be completed at the onset of ministry, and a Recommitment Form (Attachment 4) will be resubmitted every year. These forms are being used to help the church provide a safe and secure environment for the children and youth who participate in our programs and use our facilities.

Name*

First NameMiddle NameLast NameSuffix

Date

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Area CodePhone Number

Email*

example@example.com

How long have you lived at this address? blanks (If less than five years, please provide a previous address and number of years) Years: blank

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Social Security Number*

Date of Birth*

Driver's License Number*

Driver's License State

Occupation

Place of Employment

FPC member since

List other church (name & addresses) you have attended regularly during the last five years:

What leadership/volunteer experience have you had with children and/or youth? (Please be specific, and where possible, include dates and places if not at FPC Newton.)

Please list any other FPC ministries in which you are, or have been, involved:

Have you ever been convicted of, or plead guilty or nolo contendere (no contest), to traffic violations in the last five years? If yes, please describe all convictions for the past five years, any convictions resulting in the suspension of your driver's license, whether or not within the past five years.*

Is there any health-related reason that would keep you from effectively and responsibly working with children and/or youth, or cause them any potential harm? If yes, please explain.*

Do you have any medical training?

Are you CPR certified?

Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Area CodePhone Number

Relationship to you

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Area CodePhone Number

Relationship to you

The questions listed below are necessary in order to help ensure a safe and secure environment for our children and for the protection of our volunteer and/or paid staff. All information is held strictly confidential. Please answer these questions. If you have any concerns regarding the questions, please consult with the pastor.

Have you been convicted for the use or sale of drugs?*

Have you been hospitalized or treated for alcohol or substance abuse?*

Have you been arrested for a criminal offense excluding minor traffic violations?*

Have you ever been denied participation in supervising youth activities in any other organization?*

Please explain any "yes" answers.

Applicant's Statement

The information contained in this application is correct and complete to the best of my knowledge. I auhtorize any references, churches, or other organizations listed in thsi application to give you any information they may have (including employer's opinions) regarding my character and fitness for working with children or youth and I hereby release all such references, churches, or other organizations from liability for damages of whatever kind or nature that may have result from furnishing such evaluations to you. I waive any right I may have to inspect any information provided about me by any person or organization identified by me in this application.

Should my application be accepted, I agree to follow the Child and Youth Protection Policy and to refrain from inappropriate conduct in the performance of my services on behalf of the church. I understand that any violation of this Code of Conduct or misrepresentation of information that I have provided may result in termination of employment or volunteer service with children/youth.

I have no past conviction of or pending proceeding addressing an allegation of child abuse or neglect.

I authorize that a Criminal and Civil Records Check may be conducted on me and that any information which pertains to any record of convictions contained in police files or any criminal or civil file maintained on me, whether state or local, be released to the church. In so authorizing, I release any law enforcement agencies, First Presbyterian Church or those individuals receiving the results of the check from any and all liability resulting from such disclosure.

I acknowledge that I have read teh FPC Child and Youth Protection policy and have received copies for my personal use.

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 IN EXCHANGE FOR THE OPPORTUNITY TO SERVE AS AN FPC EMPLOYEE OR VOLUNTEER. This is a legally binding agreement, which I have read and understand. I understand that the personal information will be held confidential by the professional church staff.

Signature

Date

Employee and Volunteer Ministry Application Form

Personal references (Must be over 18 years old and not related to you)

Reference #1

Reference #2