Confidential Screening Form for Minors

Confidential Screening Form

Child Evangelism Fellowship Child Protection Policy
Confidential Screening Form (for minors)

This screening form is to be completed by applicants for any position, paid or volunteer, involving CEF ministries and will be used to help CEF provide a safe and secure environment for children.

This is not an employment application. Anyone interested in employment with CEF will also need to complete an employment application form.
Name*

First NameMiddle NameLast Name
Sex
Date of Birth
Example: 1/12/2012
Phone Number*

Area CodePhone Number
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Any previous addresses (for past 5 years)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Any Previous addresses (for past 5 years)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Have you ever been convicted of a crime?*

NoYes
If yes, please explain and give county and state of conviction
Have you ever been convicted of child abuse?*

NoYes
If yes, please explain.
Please explain your salvation experience (Your testimony of when you accepted Jesus as your Savior).
Is there anything that would call into question your being entrusted with the supervision, guidance, and care of children or young people? If yes, please explain.

References
Name (Pastor or church leader)*

First NameLast Name
Church*
Phone Number*

Area CodePhone Number
Email
example@example.com
Name (Personal, not relative)*

First NameLast Name
Relationship*
Phone Number*

Area CodePhone Number
Email
example@example.com
Name (Personal, not relative)*

First NameLast Name
Relationship*
Phone Number*

Area CodePhone Number
Email
example@example.com
Name (Personal, not relative)*

First NameLast Name
Relationship*
Phone Number*

Area CodePhone Number
Email
example@example.com

Background/Reference Check Authorization

Release
Release Authorization:
1. In connection with my future involvement as a staff member or a volunteer working with children, I understand the CEF will conduct a background check to determine my ability to minister in this role. It may include information concerning my character, work habits, performance, and any court records that may have a bearing on my job responsibilities.
2. I acknowledge that a telephonic facsimile (fax) or photocopy of my signature shall be as valid as the original.
3. I hereby authorize, without reservation, any law enforcement agency, institution, information service bureau, school, employer, church or non-profit organization, reference, or insurance company contact by CEF or its consumer reporting agency or its agents, to furnish the information described above.
4. I understand that if any of those records contains information which is used to prevent my involvement in Child Evangelism Fellowship, I will be notified of my rights and where I can obtain a copy of the information.
By signing below, I hereby release Child Evangelism Fellowship and its agents, officials, representatives, or assigned agencies, including officers, employees, or related personnel both individually and collectively, from any liability for damages or whatever kind, which may at any time result to me, my heirs, family, or associates because of compliance with this authorizatino and request to release information. I may be contacted as indicated below. A copy of this authorization (if not previously destroyed in accordance with record retention policies) will be given to me, provded I request it in writing.

This information contained in this screening form is correct to the best of my knowledge. I authorize any references listed on this applcation to give you any information (including opinions) they may have regarding my character and fitness for children's work. I hereby release any individual, church, youth organization, employer, charity, reference, or any other person or organization, both individually or collectively, from any and all liability for damages of whatever kind or nature which may at any time result to me, my heirs, or my family on account of compliance or any attempts to comply with this authorization, excepting only the communication of knowingly false information.

I agree to abide by the Child Protection Policy and to refrain from unscriptural conduct in the performance of my services on behalf of CEF.

I have read the Child Protection Policy and viewed or heard the Protecting Today's Child presentation and agree to follow the policies and procedures in handling any child abuse situations that may arise.

I further state that I have read carefully the foregoing release and know the contents thereof. This is a legally binding agreement which I have read and understand.
Signature (parent if minor)*

Clear
Print Name*

First NameLast Name
Date*
Should be Empty:

Confidential Screening Form

References

Background/Reference Check Authorization