Name
*
First Name
Last Name
Date
*
MM
DD
YYYY
Have you ever used name(s) other than the one listed above?
*
If yes, please list:
Current Street Address:
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Years At Address:
*
Previous Address:
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Cell
(###)
###
####
Home
(###)
###
####
Work
(###)
###
####
Marital Status
*
Email Address
*
Ministry Area(s) Of Interest (i.e. Children, Youth, etc):
*
When are you available to volunteer?
*
Current Employer:
Length Of Employment:
Name Of Supervisor:
First Name
Last Name
Phone Number:
(###)
###
####
Is there any reason you should NOT work with or around children or youth?
*
If yes, please provide details:
Have you ever been the subject of a child abuse investigation?
*
If yes, please provide details:
Have you ever been convicted of or pleaded guilty to a criminal offense?
*
If yes, please provide details:
List any education, degrees, training, certifications, etc. relevant to area of interest:
Have you made a profession of faith in Jesus Christ?
*
When?
Have you been baptized?
*
Are you a member of First Baptist Church PC?
*
If not, which church do you attend?
How long have you attended that church?
Are you a member?
*
List other churches with which you have been affiliated in the past 5 years.
List any church activities where you have been involved with preschoolers, children or youth in the past 5 years.
List any non-church activities where you have been involved with preschool, children or youth.
Name 1:
*
First Name
Last Name
Phone:
*
(###)
###
####
Address:
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Years known each other:
*
Name 2:
*
First Name
Last Name
Phone:
*
(###)
###
####
Address:
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Years known each other:
*
Name 3:
*
First Name
Last Name
Phone:
*
(###)
###
####
Address:
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Years known each other:
*
Signature:
*
First Name
Last Name
Date:
*
MM
DD
YYYY
