Preschool/Children's/Youth Volunteer Application

Name

First NameLast Name

Daytime telephone

Address

Age Range

under 1818 - 2526 or older

In which preschool/children's/youth programs do you want to become involved?

What skills would you bring to the preschool/children's/youth program?

What other preschool/children's/youth work experience do you have? (Please list organization name(s), program, dates and a contact person)

Have you at any time ever been arrested for any reason?

YesNo

Have you ever at any time been convicted of, or pleaded guilty or no contest to, any crime?

YesNo

Have you ever at any time engaged in, or been accused of, any child molestation, exploitation, or abuse?

YesNo

Are you aware of having any traits or tendencies that could pose a threat to preschoolers, children, youth, or others?

YesNo

Are you aware of any reason why you should not work with preschoolers, children, youth, or others?

YesNo

If the answer to any of these questions is "yes," please explain in detail:

Church Activity

What church or churches have you attended in the past five years? Please list church name, pastor's name and years attended.

References (Other than relatives). Please provide at least two. Include their name, their relationship to you, their email address and their phone.

Preschool/Children's/Youth Work Verification and Release

I recognize that Mt. Airy Baptist Church is relying on the accuracy of the information I have provided on the Preschool/ Children's/Youth Volunteer Application form. Accordingly, I attest and affirm that the information I have provided is absolutely true and correct. I authorize Mt. Airy Baptist Church to contact any person or entity listed on the Preschool/Children's/Youth Volunteer Application form, and I further authorize any such person or entity to provide Mt. Airy Baptist Church with information, opinions, and impressions relating to my background or qualifications. I voluntarily release Mt. Airy Baptist Church and any such person or entity listed on the Preschool/Children's/Youth Volunteer Application form from liability involving the communication of information relating to my background or qualifications. I further authorize Mt. Airy Baptist Church to conduct a criminal background investigation. I am aware of the policies and procedures of Mt. Airy Baptist Church, and I agree to abide by them and to protect the health and safety of the preschoolers, children or youth assigned to my care or supervision at all times.

(Please read this document carefully before you sign it)

Printed name

Signature

Date