Application for Paid or Volunteer Employment With Children/Youth

First Name: Add middle name after first if applicable.

Last Name:

Home Address: Street Address, City, State, Zip.

Email Address:

Primary Phone Number:

What type of position are you applying for? Examples: Paid childcare staff, volunteer religious education teacher, volunteer youth advisor

Please tell us something about why you are interested in this position.

When are you available to begin work? Please enter your earliest start date

Desired Salary (if applying for paid position):

Are you over 18 years old? If not, please indicate your age

Past Work History: Please provide a full record of all employment, paid and volunteer. Be sure to provide the following information for each job: dates, employer name, address, nature of work, and reason for leaving.

Previous residence(s) for last 7 years (include college and home residences): Include the full address, the state, and years of residency.

References: Give names, email addresses, and phone #s of three persons (not relatives of yours) with knowledge of your character, ability, and experience.

Education: Summarize your education including the year, school, city and state of school, and type of degree granted. Only include degrees beyond a high school diploma.

Do you have a valid driver's license?

Do you have a current chauffeur-type license?

Do you have a commercial driver's license?

Driver's License Number, State Issued, and Expiration Date: Only answer if applying for a position requiring driving.

Criminal Record: Have you ever been convicted of a crime, other than a minor traffic offense? If yes, explain here. If no, simply write "no." (note: a prior conviction does not automatically prevent employment. The congregation will evaluate any conviction on a case-by-case basis.)

Have you ever been convicted of any crime relating in any manner to children, youth or vulnerable adults and/or your conduct with them? If yes, explain here. If no, simply write "no."

Have you ever been adjudged liable for civil penalties or damages involving sexual or physical abuse of children, youth, or vulnerable adults? If yes, explain here. If no, simply write "no."

Have your parental rights ever been terminated for reasons involving sexual or physical abuse of children? If yes, explain here. If no, simply write "no."

I understand that the congregation may deny employment to any person who answers "yes" to any of the previous 5 questions. If hired and the congregation later discovers evidence to indicate a "yes" answer to any of the above, employment may be terminated.

I understand that employment may be terminated at any time if the employee is found to have prior complaints of child abuse, have resigned or been terminated due to complaints of sexual abuse, or have falsified or omitted information in this statement.

I understand that the information provided on this form is subject to verification, which may include a criminal history check and request from a central registry of child abusers.

I understand that this disclosure must be updated yearly.

Signature:

Signature of Minor's Parent or Guardian:

When you submit this form, you will receive an email confirming your entries.