Volunteer Application

Volunteer Application

Background Screening For Those Working With Minors
CONFIDENTIAL INFORMATION

This application contains information that is confidential and may be reviewed only by the Senior Pastor of a District Affiliated Church, Executive Officers of the Assemblies of God, Northern California & Nevada District Council, Inc., the board of directors, or persons or committees authorized by the board of directors having authority to make personnel decisions regarding volunteers and employees. Persons who review, duplicate, distribute, or disclose any portion of this document without authorization face one or more of the following consequences:
1. Possible criminal liability
2. Possible civil liability
3. Possible termination of employment, if an employee
4. Possible dismissal from any official position with the District, if a volunteer
Instructions to Applicant: Please complete this form:
(Please note that if the position you are applying for includes transporting minors, you may be asked to complete additional forms)

PASTORAL REFERENCE
Pastoral reference should be from a current Lead Pastor or Pastor you are serving in ministry under (youth pastor, kids pastor, etc.) on a regular basis.
Name of Pastoral Reference:*
Pastoral Position (Lead, Youth, Kids, etc.):*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Pastoral Ref. Email*
example@example.com

EXPERIENCE WORKING WITH MINORS
Please list up to three of your previous experiences where you worked with minors beginning with your current or most recent. [If you have less than three prior experiences, please list all that you have.]
Please select how many experiences you have to list:*
Experience #1

Current or Most Recent
Church/Organization Name:*
Position*
Address:*
Start Date/Ending Date (Month/Year):*
Name of Supervisor (Contact), Title & Phone*
Reason for Leaving:*
Description of Duties:*
Experience #2

Second Most Recent
Church/Organization Name:*
Position:*
Address:*
Start Date/Ending Date (Month/Year):*
Name of Supervisor (Contact), Title & Phone:*
Reason for Leaving:*
Description of Duties:*
Experience #3

Third Most Recent
Church/Organization Name:*
Position:*
Address:*
Start Date/Ending Date (Month/Year):*
Name of Supervisor (Contact), Title & Phone:*
Reason for Leaving:*
Description of Duties:*

APPLICANT'S STATEMENT
Please write a brief statement explaining why you are seeking a volunteer position with the District and describe why you want to work with minors and would make a good volunteer:
Applicant's Statement:*
The information contained in this application is correct to the best of my knowledge. I authorize any references or churches listed in this application to give you any information they have regarding my character and fitness for working with minors and I release all such references from liability for any damage that may result from furnishing such evaluation to you.

Should my application be accepted, I agreed to be bound by the bylaws and policies of the Assemblies of God, Northern California and Nevada District Council, Inc., and to refrain from unscriptural conduct in the performance of my services on behalf of the church and/or District.

I understand that after two consecutive years of non-participation in District camps, my volunteer status will be changed to inactive. If after being moved to inactive status, I choose to return as a volunteer, I agree to resubmit a new volunteer application and undergo the Live Scan screening process again.

In signing this application, I affirm that the information I have given here is true and correct.
Applicant's Signature

Clear
Date/Time
As part of the screening process, AGNCN requires all volunteers to complete mandated reporter training. If you have already completed this training, please upload a copy of the training certificate here, or if you do not have it available at this time, an upload link will be provided in your email confirmation.

Upon approval of your volunteer application, an email will be sent to you with the Request for Live Scan form and instructions on where you can go to be Live Scanned.
Mandated Reporter Training Certificate Upload

Cancelof
Should be Empty:

Volunteer Application

Legal History

Experience #1

Experience #2

Experience #3