Volunteer Screening Form
(850) 640-2022 | Panama City, Florida
Today's Date
-
Month
-
Day
Year
Date
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Secondary Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Occupation
Marital Status
Date of Birth
-
Month
-
Day
Year
Date
Drivers License #
State
Enter Issuing State of Drivers License
Emergency Contact Name
Emergency Contact Number
Have you ever been charged, indicted, or pled guilty to an offense involving a minor?
*
Yes
No
If Yes, please list all convictions:
FOR STAFF ONLY: Staff Verified?
Yes
No
FOR STAFF ONLY: Notes
FOR STAFF ONLY: Approved?
Yes
No
FOR STAFF ONLY: If No, please list why?
Back
Next
CHURCH ACTIVITY
Have you made a profession of faith in Jesus Christ?
Yes
No
If Yes, When?
Have you been Baptized?
Yes
No
Do you hold a membership at any church?
Yes
No
Please list the names of any other church you have regularly attended over the past five years:
Please list any church activities or services where you’ve been involved:
PERSONAL CHARACTER REFERENCES
(please do not list employment or relatives)
Reference 1: Name
First Name
Last Name
Reference 1: Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Reference 1: Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Reference 2: Name
First Name
Last Name
Reference 2: Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Reference 2: Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Reference 3: Name
First Name
Last Name
Reference 3: Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Reference 3: Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Signature
Continue
Continue
Should be Empty: