Name *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth

MM

DD

YYYY

Home Phone #

(###)

###

####

Cell Phone #

(###)

###

####

Work Phone #

(###)

###

####

Do you regularly attend (2 or more services a month)?

Yes

No

Are you a member?

Yes

No

Have you been water baptized?

Yes

No

Are there any circumstances involving your lifestyle or history that could call into question your ability to work safely with children or youth in a Christian environment?

Yes

No

Have you ever been convicted or found guilty of a criminal offence for which a pardon has not been granted? (Note: This does not include minor traffic violations) If yes, please list offence(s) and the date(s) of conviction.

Yes

No

Have you ever been expelled from or had your employment terminated by any organization or employer for assault or violence against any person, or assault, violence or impropriety with children, youth or vulnerable persons?

Yes

No

Have you ever been investigated by the Child Welfare Agency or any other organization for suspected child abuse?

Yes

No

Have you ever been a defendant or respondent in a civil lawsuit or human rights complaint or other legal proceeding in which you were alleged to have abused or engaged in violence, harassment or other immoral or illegal behaviour or conduct involving children, youth or vulnerable persons?

Yes

No

Do you have any health concerns which could impact your ability to perform the functions of the volunteer position for which you are applying? (Please note that such health concerns may not prevent you from holding the position for which you have applied).

Yes

No

Do you have any contagious diseases or conditions of which we should be aware and which we may need to take steps to protect against transmission at the Church?

Yes

No

1. Name of Reference

First Name

Last Name

Day Phone #

(###)

###

####

Evening Phone #

(###)

###

####

2. Name of Reference

First Name

Last Name

Day Phone #

(###)

###

####

Evening Phone #

(###)

###

####

3. Name of Reference

First Name

Last Name

Day Phone

(###)

###

####

Evening Phone

(###)

###

####

I hereby give the church consent to verify the information provided by me in this Ministry Personnel Application Form to contact the references and obtain and verify any information from them (and any other persons or sources that the Church determines might be able to provide relevant information) that may be relevant to my application. I agree to obtain and hand over a Criminal Record Check and allow the Church to keep it on file. I understand that if the church approves my volunteer application and later determines, in its discretion, at any time that I am not suitable for volunteer service in the church of for the volunteer position for which I am applying, the church may terminate my volunteer service or volunteer position for any reason without advance notice. If the church approves my application for a volunteer position, I will sign any documents that the church requires and will at all times cooperate fully with staff of the church in the fulfillment of my duties and will keep all confidential information I encounter in my role as a volunteer, confidential. If at any time I determine that for any reason I am unable to support or adhere to or follow the policies, procedures or doctrine of the church, I will inform the church and resign from my position. I hereby acknowledge that, to the best of my knowledge, the information contained in this Ministry Personnel Application Form is true and correct. *

Agree