Primary Screening Form for Children or Youth Work
Confidential
Milord United Methodist Church
327 North River Rd, Milford, New Hampshire 03055
1. This application is to be completed by all applicants for any position (volunteer or compensated) involving the supervision or custody of minors. This is not an employment application form. Persons seeking a position in the church as a paid employee will be required to complete an employment application in addition to this screening form. It is being used to help the church provide a safe and secure environment for those children and youth who participate in our programs and use our facilities.
Personal
2. Date_____________________________________________________________________
Name____________________________________________________________________
Last First Middle
3. Identity must be confirmed with a state driver 's license or other photographic identification
Present Address__________________________________________________________
City_____________________________________________________________________
State_______________ Zip Code______________ Home Phone (___)_______________
Occupation_______________________________________________________________
Employer_________________________________________________________________
Please indicate the type of youth or children's work you prefer_____________________
Please indicate the date you would be available to begin_________________________
What is the minimum length of commitment you can make?_______________________
4. Would You be willing to drive occasionally, and if so do you have a current and valid driver's license? Yes or No
Has it ever been suspended or revoked? Yes or No
If yes. please explain_________________________________________________
Do you have your own transportation?__________________________________________
List your liability insurance carrier and the policy limits_____________________________
5. At an interview (with the pastor) you will be asked if you were a victim of abuse or molestation while a minor. If so, the impact on your current ability to work with children or youth will be discussed
6. Have you ever been convicted of or pleaded guilty to a crime?
No _____________
Yes____________ Be prepared to discuss this during your interview.
Church History and Prior Work with Children/Youth
7. Name of church of which you are a member: _____________________________
List (name & address) other churches you have attended regularly during the past five Years:
__________________________________________________________________________
__________________________________________________________________________
8. List all previous church work inolving children or youth during the pas five years (list each church's name & address, type of work performed, and dates) _______________________
__________________________________________________________________________
__________________________________________________________________________
9. List all previous non-church work involving children or youth during the past five years (list each organization's name and address, type of work performed) _____________________
__________________________________________________________________________
__________________________________________________________________________
10. List any gifts, callings, training, education, or other factors that have prepared you for children or youth work: _____________________________________________________________
__________________________________________________________________________
11. Personal References (not former employers or relatives)
Name________________________________ Name________________________________
Address______________________________ Address______________________________
_____________________________________ _____________________________________
Telephone____________________________ Telephone_____________________________
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 opinion) that they may have regarding my character and fitness for children and youth work. In consideration of the receipt and evaluation of this application by Milford United Methodist Church, I hereby release any individual, church, youth organization, charity, employer, reference, or any other person or organization, including record custodians, 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 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 abide by the Child/Youth Protection Policy of Milford United Methodist Church, and to strive to conduct myself as a follower of Christ 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 I SIGN THIS RELEASE AS MY OWN FREE ACT. This is a legally binding agreement, which I have read and understand.
Applicant's Signature_________________________________ Date______________________
Witness____________________________________________ Date______________________