Lay Counselor Renewal Application Form

Lay Counselor Renewal Application Form

Salem Heights Church
Name*

First NameLast Name
Daytime Phone*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Why do you want to continue serving in the lay counseling ministry?*
Background Information
Since your initial application, have you participated in sexual misconduct? Since your initial application, have you been accused of, pleaded guilty or no contest to, or been convicted of abuse or any sexual misconduct?*

YesNo
If Yes, please explain:
Since your initial application, have you ever been convicted of or pleaded guilty or no contest to any criminal offense of any kind?*

YesNo
If Yes, please explain:
Since your initial application, have you identified any personal traits/tendencies that could pose a threat to others?*

YesNo
If Yes, please explain:
Lay Counselor Renewal Release
I recognize that Salem Heights Church is relying on the accuracy of the information I provide on the Lay Counselor Renewal Application Form. Accordingly, I attest and affirm that the information I have provided is absolutely true and correct.

I voluntarily release the organization and any such person or entity listed on the Lay Counselor Renewal Application Form from liability involving the communication of information relating to my background or qualifications. I further authorize the organization to conduct a criminal background investigation.

I agree to abide by the policies and procedures of the organization and to protect the health and safety of the lay conselees assigned to my care at all times.
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Lay Counselor Renewal Application Form

Background Information

Lay Counselor Renewal Release