REGIONALCHURCH - VOLUNTEER INFORMATION & SCREENING FORM

Regional Church

CONFIDENTIAL VOLUNTEER INFORMATION & SCREENING FORM
Delbarton Church of God dba Regional Church of God, Regional Church, "RCOG"

*House of Hope, Inc. "HOH"

*Partnering Ministry of Regional Church of God

881 Rt 52

PO Box 236

Delbarton WV 25670

Phone 304.475.3468 Fax 304.475.5287

Website: www.regionalchurch.org

Email: info@regionalchurch.org
We are excited to have you involved in an area of ministry that will use your talents and spiritual gifts for the Lord. In order for us to responsibly provide a safe environment for our children and youth who participate in programs, we are obligated to request some specific information. This application is to be completed by ALL applicants for ANY position (volunteer or compensated) involving interaction with the supervision or custody of minors. This is NOT an employment application form. Persons seeking a position in the church as paid employees are required to complete an employment application in lieu or addition to this Volunteer Information & Screening Form. This form is being used to assist the church and partnering ministries in providing a safe and secure environment for those children and youth who participate in our programs and have access to our facilities. All volunteers working with youth or children must be a member or faithful attendee of RCOG for a minimum of six months, or may apply for an exception by providing a pastoral recommendation from their most recent church membership.
Legal Name*

First NameMiddle NameLast NameSuffix
Nickname or Preferred Name
Maiden Name, if Applicable
Primary Phone Number*
Format: (000) 000-0000.
Cell Phone Number
Format: (000) 000-0000.
Alt/Work Number
Format: (000) 000-0000.
Social Security Number (required for background check)*
Date of Birth*

MonthDayYear
Drivers License Number (If none, enter "NONE")*
Please Check the Type of Drivers License You Have*

Regular LicenseChauffer's LicenseCDL License (must have passenger endorsement to drive church bus)Other
State in Which Your Drivers License Is Issued
Have you been involved, charged, fined, or convicted of a traffic violation or motor vehicle accident within the last three years? If yes, please describe all charges, fines, or convictions.
Please upload a legible photo or pdf file of your drivers license or government-issued photo ID, or use the camera option to take a snapshot of your license/ID:

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If using your phone or tablet, you may take a snapshot of your drivers license or ID:
Gender*

MaleFemale
E-mail*
example@example.com
Marital Status
Spouse's Name
Serving Together?
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
If a Student, the Name of the School You Attend
Place of Employment (If Retired or Unemployed, Please Indicate)
Job Title
Length of Employment
Ministry Area in Which You'd Like to Serve (Check All That Apply)

RCOG Nursery/PreschoolRCOG Children's MinistriesRCOG Youth/Student MinistriesRCOG Adult MinistriesRCOG Shut-Ins MinistryRCOG Lay MinistryHouse of Hope Food Bank (HOH)Other Ministry (Specify)
In What Type of Ministry-Related Functions Do You Prefer to Be Involved?

What Hours Are Possible For You to Serve at the Church?

Rows	Not Available	Available Any Hours	Only Available Specified Hours* (Specify Below)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

*Notes Section for Specified Hours on Certain Days
What Date Would You Become Available to Begin Serving?
Estimated Time of Commitment?
Do You Speak Any Foreign Languages? If So, Please List
Do You Know How to Communicate in Sign Language for the Hearing Impaired?

YesNo
Briefly Describe Your Relationship With Jesus Christ*
I am a/an:0*

MemberAttendeeAffiliate in Ministry but Member/Attendee of Another Church (Please List Below)I do not attend any churchOther
How long have you attended Regional Church?*
If You Are a Member/Attendee of Another Church, Please Provide Name and Address of Church and Indicate How Long You Have Been a Member There
Please List (Name and Address) Additional Churches You Have Previously Been A Member/Regular Attendee During the Past Five Years
List Any Leadership/Volunteer Experience, Work Experience, Job Skills or Hobbies You Have Had that Might Be Helpful for Us to Know: (If None, Enter "NONE")*
If You Have Any Certifications, Letters of Recommendation, Etc., that You'd Like to Share with Us, You May Upload Them Here:

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List Any Training, Education or Spiritual Gifts That Have Shaped You to Serve in the Church, Or That May Be Helpful for Us to Know (If None, Enter "NONE")*
List Any Regional Church Ministries In Which You Are or Have Already Been Involved:
T-Shirt Size (In Case We Order You a T-Shirt)*

SMLXLXXLXXXLXXXXLOther
CRIMINAL OFFENSE RECORD

Note: We reserve the right to limit participation and/or deny volunteer applications for any persons who answer yes to these questions, especially when applying for ministry to children and minors. No person convicted of or having pleaded guilty to child molestation, child assault/abuse, lewdness, or any sex offense charges may participate in ministry to our babies, children, teens, the physically/mentally incapacitated, or the infirm. If it is later determined that you answered these questions dishonestly, your participation as a ministry volunteer will be subject to revocation.
During Your Lifetime, Have You Ever Been Accused, Convicted, or Pleaded Guilty of Child Molestation, Child Assault/Abuse, Lewdness, or Sex Offences of Any Nature? If Yes, Please Explain the Nature of the Accusation, Charge or Conviction.*
Have You Ever Been Accused, Convicted, or Pleaded Guilty to Any Other Crime? If Yes, Please Explain.*
Are you aware of having any traits or tendencies that could pose any threat to children, youth, or others? If yes, please provide detailed explanation.*
Are you aware of any reason why you should not work with children, youth, or others? If yes, please provide detailed explanation.*
Local Personal References (Must Be 18 Years Old and Not Related to You)
Reference #1 Name

First NameLast Name
Reference #1 Phone Number
Format: (000) 000-0000.
Reference #1 E-mail
example@example.com
Reference #1 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Reference #2 Name

First NameLast Name
Reference #2 Phone Number
Format: (000) 000-0000.
Reference #2 E-mail
example@example.com
Reference #2 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Local Church Ministry Leader Reference

(In This Section, Please List a Pastor, Bible/Small Group Teacher, Youth/Young Adult Pastor, Church Employee or Member Who Knows You Well Enough to Give a Reference)

Note: Volunteers 14-21 years of age MUST include a Bible/Small Group Teacher or Youth/Young Adult Pastor)
Local Church Reference's Name

First NameLast Name
Local Church Reference's Phone Number
Format: (000) 000-0000.
Local Church Reference's E-mail
example@example.com
Local Church Reference's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

AUTHORIZATION FOR REFERENCE CONTACT(S) AND BACKGROUND CHECK
I recognize that Delbarton Church of God dba Regional Church of God is relying on the accuracy of the information I provide on this Volunteer Application Form. Accordingly, I attest and affirm that the information I have provided is absolutely true and correct. I hereby authorize Delbarton Church of God dba Regional Church of God (hereinafter referred to as "Regional Church"), through its independent contractor (currently Shepherd's Watch/First Advantage, but independent contractor is subject to change without notice), to obtain a background check (also known as a "consumer report and/or investigative consumer report") about me. This report may include my driving history, including any traffic citations; a Social Security number verification; present and former addresses; criminal and civil history/records; sex offender records on any municipal, county, state, or national registries; to verify all information contained in this application with any references, my past or present employers, any other appropriate personnel at my past or present employment, churches or other organizations, and any individuals. I authorize those who are contacted to disclose any and all information to Regional Church of God. I release all such persons or entities from liability that may result or arise from Regional Church’s collections of all such evaluations or information for its consideration of my application. Should my application be accepted, I agree to follow the policies of Regional Church and its Affiliated Ministries to refrain from unscriptural conduct in the performance of my services on behalf of the church. I understand that this personal information will be held confidential by the church staff. I also authorize Regional Church to re-conduct background checks automatically every three years (or sooner, if deemed necessary) for as long as I attend the church or the church's functions. Furthermore, I understand that I am entitled to a complete copy of any background information report of which I am the subject (upon my request to authorize Regional Church, if such is made within a reasonable time from the date if was produced). I also understand that I may request a written summary of my rights under the Fair Credit Reporting Act.*

I Agree with the Statement AboveI Disagree with the Statement AboveI Am the Parent/Legal Guardian Signing on Behalf of the Applicant and I Agree with the Statement AboveI am the Parent/Legal Guardian Signing on Behalf of the Applicant and I Disagree with the Statement Above
Signature __________________________________Date_________ *
Date

MonthDayYear
Date
Should be Empty:

Regional Church