Staff Application

Employee Application
This application and the information provided will be reviewed by qualified Clarity Clinic staff and will remain confidential. Involment at Clarity Clinic, including training, can begin only after the complete Application, Personel Forms, and Background Check are returned to Clarity Clinic.
A) Demographic Information
Name
Date

MonthDayYear
Date
Address
Phone
Email
example@example.com
Birthdate

MonthDayYear
Date
What position are you applying for?
Why would you like to work at Clarity Clinic?
Emergency Contact
Phone
Relationship
EDUCATION
High School: Number of years completed:
Diploma:

YesNo
G.E.D.:

YesNo
School Name:
College and/or Vocational School: Number of years completed:
School(s)
Degree(s) earned:
Dates

MonthDayYear
Date
B) Abortion & Adoption Experiences
Have you had any personal experiences with abortion or adoption?

YesNo
If yes, would you be willing to share more regarding your experience with trusted Clarity Clinic personal?

YesNo
When do you believe human life begins, and what is your belief on abortion?
February 24, 2026

C) Relevant Skills & Experience
Please provide us with information about skills you may have. These can be office skills, computer skills, medical skills, counseling skills, etc.
Please describe any experience you think may be relevant to working at Clarity Clinic. This can be employment, volunteer experiences, occupational training, public speaking, etc.

Please describe any experience you think may be relevant to working at Clarity Clinic. This can be employment, volunteer experiences, occupational training, public speaking, etc.

Rows	Organization / Company	Job Title	Responsibilities
1

D) Personal Faith
Clarity Clinic is a Christian, non-denominiational, pro-life ministry. As such, it is vital that all employees have a personal relationship with God and eternal hope through salvation in Jesus Christ. We believe that our faith in Jesus Christ empowers us, enables us, and motivates us to provide faith-filled pregnancy services in this community.
Please write a brief statement about your salvation story and your personal faith in Jesus Christ.
E) Areas of Interest
Please indicate the roles you are interested in.
Areas of Interest

Patient ResourcesOffice SupportAdvancementMarketingOther
Patient Resources: Kidzone Care, Processing Room, Receptionist, Men's Support
Office Support: Receptionist/Clerical, IT Support, Cleaning/Janitorial, Facilities Maintenance
Advancement: Church Relations, Mailing Assistant, Data Entry Specialist
Marketing: Graphic Designer, Fundraising Committee, Demographic Researcher
F) References
Involvement with Clarity Clinic requires two references, one from your current Pastor and one from a person who knows you well and for longer than a year. The personal reference cannot be an immediate family member. You are responsible for getting the Reference Forms located at the end of this Application to the people who will complete the forms on your behalf.
Please list the two people who will be completing the Reference Forms for you.
Professional:
Relationship:
Phone:
Professional:
Relationship:
Phone:

G) Signature of Agreement and Commitment
Previous Address 3

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Having carefully read and completed this Application, I, the undersigned, agree that:
- I have provided information that is accurate,
- I will uphold the Mission, Values, and Strategy of Clarity Clinic,
- I will uphold the Positional Statements as stated,
- I will uphold the Commitment to Standards and Non-Disclosure as stated, and
- I have included, below, any questions, concerns, or differences as I presently have them.
Signature

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Print Name
Date

MonthDayYear
Date
Questions/Concerns/Differences
Below this point is for Clarity Clinic management only.
Application Review
Check each item below when they are complete.
- Content of this Application has been reviewed and found to be complete and satisfactory.
- A Resume has been provided (with professional references if applying for a paid staff position).
- Questions, concerns, or differences the applicant has included in this Application have been discussed with the applicant.
- Both Reference Letters have been received and reviewed. (Not applicable for Advancement and Office Support positions.)
- Pastoral reference has been contacted for reference follow up. (Not applicable for Advancement and Office Support positions.)
- Proof of necessary licenses or certifications has been provided, when applicable for the positions (for example, nurse).
- The Signature of Agreement and Commitment has been signed by the applicant.
- The Staff and Volunteer Service Commitments document has been signed and given to the applicant.
- The applicant has been appropriately interviewed for the position requested or assigned.
Applicant Approval or Denial
Check the appropriate decision below after the Application Review is complete.
Start date

MonthDayYear
Date
Position
Wage
The applicant is asked to resolve some issues (described below) and then apply againThe applicant is denied. (Indicated below.)
Clarity Clinic Management Signature of Review [Office Use Only]

BACKGROUND RELEASE FORM(Required for all Applicants)
In connection with this application for employment, I understand that an investigative consumer report may be requested now, and in the future as terms of my continued employment. This report may include information pertaining to my character, education, work history, credit history, motor vehicle records, and criminal information contained within any government agency, Federal, State, or Local. This information shall include, but not be limited to, verified by any statements made on my application.

I hereby authorize all corporations, companies, credit agencies, educational institutions, persons, law enforcement agencies, military services, and former employers to release information they may have about me to Company or its agents, and do forever release them from any liability or responsibility for doing so to the fullest extent allowed by law from any claims arising from the requested information.

If required, I specifically authorize a credit report to be obtained on myself.

I recognize and agree that a copy or facsimile of this document shall be as valid as the original.

I recognize and agree that this release shall be valid for this and any future update reports requested.

According to the Fair Credit Reporting Act, I am entitled to know if employment is denied based on information contained in this report, and to receive, upon written request, a disclosure of the public record information as well as the nature and scope of the investigative report.
Phone: (required)*
eMail: (required)*
example@example.com
ALL FIELDS ARE REQUIRED TO BE COMPLETE BEFORE RETURNING:
Name

First NameMiddle NameLast Name
Social Security Number
Date of Birth

MonthDayYear
Date
Driver's License Number
State of Issuance
Current Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please list any previous addresses you have had in the past 7 years:
Previous Address 1

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Previous Address 2

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please list any former names (I.e. maiden or otherwise) you have used in the past 7 years:
Date

MonthDayYear
Date
Signature

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Before you submit this application, please click HERE . There are two forms that you will need to print and provide to your Pastoral/Priest and your Character Reference.

Thank you.
Should be Empty:

Employee Application

A) Demographic Information

EDUCATION

B) Abortion & Adoption Experiences

C) Relevant Skills & Experience

D) Personal Faith

E) Areas of Interest

F) References

G) Signature of Agreement and Commitment

Application Review

Applicant Approval or Denial

Clarity Clinic Management Signature of Review [Office Use Only]

BACKGROUND RELEASE FORM(Required for all Applicants)

ALL FIELDS ARE REQUIRED TO BE COMPLETE BEFORE RETURNING: