Church SafeCARE Application

It is the goal of this church to create a safe and secure environment for all children and workers who are involved in church activities. To facilitate this emphasis, it is necessary to gather pertinent information from those who desire employment or offer volunteer services to our children and youth programs. This information will be used for the sole purpose of helping the church provide a safe and secure environment for children and workers.

Name:

Date:

Date of Birth:

Social Security Number:

Specific Ministry or Department

Children Youth VBS

Have you ever used name(s) other than the one above? If yes, please list:

Current Street Address

Years at Address:

Previous Address:

Cell Phone:

Work Phone:

Please respond to all questions below that apply to the position for which you are applying/volunteering.

Position applying/volunteering for:

When are you available to work?

Do you have a valid driver’s license?

Yes No

Commercial License?

Yes No

License Number:

State Issued:

Current Employer:

Length of Employment:

Name of supervisor:

Phone number:

Email Address:

Previous employers (within last five years):

Employer:

Dates employed:

Employer:

Dates employed:

Employer:

Dates employed:

Is there any reason you should NOT work with or around children or youth?

Have you ever been the subject of a child abuse investigation?

Yes No

If yes, please provide details:

Have you ever been convicted of or pleaded guilty to a criminal offense?

Yes No

If yes, please provide details:

Please list your education background:

Name Graduate Year, Degree or Course of Study:

High School:

College:

Other:

Please provide the following church information:

What, if any, church affiliation do you have?

How long have you attended that church?

Are you a member?

Yes No

List other churches with which you have been affiliated:

Have you ever worked with youth or children?

Yes No

List where and in what capacity:

Do you ascribe to the fundamentals of the Christian faith as found in the Apostles Creed below?

Yes No

I believe in God, the Father Almighty,
the Maker of heaven and earth,
and in Jesus Christ, His only Son, our Lord:
Who was conceived by the Holy Ghost,
born of the virgin Mary,
suffered under Pontius Pilate,
was crucified, dead, and buried;
He descended into hell.
The third day He arose again from the dead;
He ascended into heaven,
and sitteth on the right hand of God the Father Almighty;
from thence he shall come to judge the quick and the dead.
I believe in the Holy Ghost;
the holy catholic church;
the communion of saints;
the forgiveness of sins;
the resurrection of the body;
and the life everlasting.
Amen.

Please list two references other than family (one should be of a member of Pinewood):

Name:

Phone:

Email:

Year known each other:

Name:

Phone:

Email:

Year known each other:

Conclusion

I hereby authorize Pinewood Presbyterian Church (Pinewood) and/or its agents to make an independent investigation of my background, references, character, past employment, education, criminal, or police records, including those maintained by both public and private organizations and all public records for the purpose of confirming the information contained on my Application and/or obtaining other information, which may be material to my qualifications as a volunteer or for employment now, and if applicable, during the tenure of my volunteering or employment with Pinewood. I release Pinewood and/or its agents and any person or entity, which provides information pursuant to this authorization, from any and all liabilities, claims, or lawsuits in regards to the information obtained from any and all of the above referenced sources used. I’ve been provided with and have read the Safe CARE policy.

By Checking this box, you agree to all terms listed above.

Name:

Date:

Church SafeCARE Application

Description

Please Fix the Following