Clearances: Step 4 - Safety Application

Clearances: Step 4 - Safety Application

Safety Application can be downloaded and printed, or filled out electronically.
CONFIDENTIAL
This application should be completed by all applicants for any position involving the supervision of or interaction with minor children or students. This is not an employment application. The purpose of this form is to assist in the creation of a safe environment for children or students who participate in the programs of Covenant Fellowship Church or use Covenant Fellowship Church facilities.

Print Version
Download and print Safety Application
Completed Safety Application

Choose File
Completed Safety Application can be submitted here. Cancelof

Online Version
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number

Area CodePhone Number
Date of Birth

MonthDayYear
Date
Gender

MaleFemale
Marital Status

SingleMarriedSeparatedDivorcedWidowed
How long have you lived at your current address?
Previous Address
List all other cities and states where you have lived as an adult and years of residency.
Please check one of the following Categories of Service

Parent of Promise Kingdom childServing on a Ministry Team (Sound, Medical Response, Photography, etc.) with access to children's ministryServing in Promise Kingdom, Compass, Bridge Kids, Vacation Bible School, Cross Culture, or YouthCamp as a teacher, helper, or leader, thus working with children directly.
For those working directly with children, please answer the following questions. All others, please skip to Question 3.
1. Please list all previous volunteer work or employment involving children or students.
List each organization's name and address, type of work, dates, and a contact person familiar with your work there. Use back of this page for more space, if necessary.
2. Why do you want to work with children or students at Covenant Fellowship Church?
For all Categories of Service, please complete the following questions.

Because we care for children and desire to protect them, please answer the following questions. We understand that the answers to these questions may be private and deeply personal, and we will protect your privacy.
3. Do you have a preference concerning the age group or sex of children or students with whom you serve with? Why?
4. What is your philosophy concerning re-direction or discipline of children other than those related to you (children, grandchildren, etc.)?
5. When you are unhappy, angry, or emotional about a person or circumstance, what do you do?
6. Have you experienced any significant physical or emotional stressors within the past year, such as the loss of a parent, spouse, child, extreme ill health, or any emotional or physical crisis? If so, please briefly explain.
7. Have you ever physically or sexually abused a child?
8. Has someone ever accused you of abusing a child?
9. Is there any reason, currently, or in the past, that it might not be good for you to work with children?
10. Would you like to speak directly to a pastor about any of the above four questions, this application, or your own personal experience?
RELEASE

I authorize Covenant Fellowship Church to contact all individuals, organizations and references listed on this Safety Application Form in order to verify the information I have provided. I agree to release from liability any person or organization that provides information related to me, including those persons I have listed as references, as well as contact persons from my previous volunteer work or employment with children.

I specifically authorize Covenant Fellowship Church to undertake a criminal background check concerning my past.

I understand and agree that any information received from the background check and application verification will not be disclosed to me except as required by law, and I hereby waive any right I may have to inspect any information provided about me by any person or organization identified by me on this form.

By signing this form, I certify and affirm that the information I have given on this form is true, complete and correct in all respects.
Signature
Date

MonthDayYear
Volunteer Statements and Agreed Code of Conduct

Please initial each of the following statements.
I declare that all statements contained in my Safety Application Form are true. I understand that any misrepresentation or omission is cause for dismissal from any program involvement.
I understand that my references and contacts from prior volunteer or employment with children or students may be contacted and that an appropriate criminal background check will be conducted. I authorize investigations of all statements contained in this application. I specifically authorize Covenant Fellowship Church to undertake a criminal background check of my past.
I understand that I must be screened before I begin service as a volunteer in Covenant Fellowship Church children's ministry programs or ministries.
I understand that I can withdraw from the application process at any time.
I understand that Covenant Fellowship Church has a policy of ZERO TOLERANCE FOR ABUSE and takes all allegations of abuse seriously. I further understand that Covenant Fellowship Church cooperates fully with the authorities to investigate all cases of alleged abuse. Abuse of any kind of grounds for immediate dismissal from my volunteer position, and m ay result in criminal charges.
I am not a pedophile or child molester. I have not perpetrated physical abuse, sexual abuse, emotional abuse or neglect against a child or student and I have never been accused of these acts.
I have never viewed child pornography.
I understand and agree that false statements regarding past conduct and/or present situations may be grounds for termination of any volunteer position, and failure to reveal the contents of a sealed criminal record will result in the automatic denial of the application and opportunity to serve as a volunteer.
I understand that Covenant Fellowship Church reports all child sexual abuse and I agree to report all acts of suspicions of child sexual abuse.
If accepted as a volunteer, I agree to read and abide by all Policies and Procedures provided to me by Covenant Fellowship Church.
Signature
Date

MonthDayYear
For Office Use Only
I have reviewed this application and have noted any missing information.
Should be Empty:

Clearances: Step 4 - Safety Application

Volunteer Statements and Agreed Code of Conduct