APPLICATION FOR ADULT WORKERS IN CHILDREN’S MINISTRY
CONFIDENTIAL
This application is to be completed by all applicants (volunteer or compensated) who are involved in the
supervision or custody of minors. This is not an employment application form. Persons seeking a position
in the Children’s Ministry, as a paid employee, will be required to complete an employment application in
addition to this screening form The purpose of this form is to help the church provide a safe and secure
environment for those children who participate in our programs and use of our facilities.
GENERAL INFORMATION
Date_________________
First Name________________________________ Last Name ________________________________
Address_____________________________________City___________________________________
Home Phone ( ) __________________________ Work ( )________________________________
Cellular Phone ( ) ___________________________Pager ( )______________________________
E-Mail Address________________________________Fax______________________________________
MINISTRY INFORMATION
1) Are you are a member of the church?
�� Yes
�� No
If yes, since when: Month________ Year________
2) Do you regularly attend services?
�� Yes
�� No
If yes, since when: Month___________ Year______________
3) Do you regularly attend a Bible Study or have quiet time with the Lord?
�� Yes
�� No
4) In what area (s) of ministry are you currently involved? ____________________ How Long? ______
5) Have you personally accepted Jesus Christ as your Lord and Savior and are you committed to having the
character of Jesus live through you?
�� Yes
�� No
6) Tell us about your spiritual journey to date:
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7) I have chosen to work with the children because:
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8) If there has been alcohol, drug abuse, and physical or sexual abuse in your family background, what
steps have you taken to minimize the impact that those issues will create for you, both now and in the
future?
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EMPLOYMENT HISTORY
Current Employer_______________________________________________________________________
Address______________________________________City________________St_________Zip________
Supervisor___________________ Phone Number __________________ Current Position_____________
MILITARY SERVICE
Branch____________________ Rank ________________________ Discharge____________________
PERSONAL SITUATIONS
1) Are you?
�� Single
�� Married
�� Widowed
�� Divorced
2) Do you have children of your own?
�� Yes
�� No
Ages ______________________ Gender _______________________
3) Have you ever been arrested, convicted or pleaded guilty to a crime?
�� Yes
�� No
If yes please explain
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4) Have you ever been suspected, accused, charged, or alleged to have, or have you ever committed an act
of neglecting, abusing or molesting a child?
�� Yes
�� No
If yes please explain:
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5) Is there any circumstance or pattern in your life that may make it inappropriate for you to work with
children?
�� Yes
�� No
If yes please explain:
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6) Have you ever been treated for a psychiatric disorder?
�� Yes
�� No
If yes please explain:
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REQUEST FOR CRIMINAL BACKGROUND RECORDS CHECK AND AUTHORIZATION
I hereby request and authorize the release of any information which pertains to any record of convictions
contained in law enforcement files or in criminal files maintained on me, whether local, state, federal or
military. I hereby release local, state, federal or military agencies from any and all liability resulting from
such disclosure.
Print Name ___________________________________
Print Maiden Name _____________________________
Date of Birth __________________________________
Place of Birth __________________________________
Driver’s License Number _________________________
SS # _________________________________________
Signature _____________________________________ Today’s Date ____________________
APPLICANT’S STATEMENT
The information contained in this application is correct to the best of my knowledge. I authorize any
references or churches listed in this application to give you any information (including opinions) they have
regarding my character and fitness for work with children. I authorize the release of information contained
in this application to any ministry of ______________________________________ in which I seek a
position (volunteer or compensated). In consideration of the receipt and evaluation of this application by
_____________________________, I hereby release any individual, church, children’s organization,
charity, employer, reference, or any other person or organization, including records custodian, both
collectively and individually, from any and all liability for damages of whatever kind or nature which may
at any time result to me my heirs, or family, on the account of compliance or any attempts to comply, with
this authorization. I waive any right that I may have to inspect any information provided about me by any
person or organization identified by me in this application.
Should my application be accepted, I agree to refrain from unscriptural conduct in the performance of my
services on behalf of the church.
I further state that I HAVE CAREFULLY READ THE FORGOING RELEASE AND KNOW THE
CONTENTS THEREOF AND SIGN THIS RELEASE OF MY OWN FREE ACT. This is a legally
binding agreement I have read and understand.
Applicant’s Signature ______________________________ Date ________________
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