CENTERVILLE PRESBYTERIAN CHURCH
4360 CENTRAL AVE :: FREMONT, CA 94536 :: (510) 793-‐3575
INTERN TO YOUTH MINISTRIES APPLICATION
PLEASE COMPLETE ALL PAGES OF THIS APPLICATION AND RETURN IT TO MATT KNAPP AT CENTERVILLE PRESBYTERIAN CHURCH BASIC INFORMATION First Name: ____________________________ Last Name: ________________________________ M.I. ___________ Date of Birth: ________ / _________ / __________ Address: ________________________________________________________ City: _________________ Zip: _____________ Home Phone: (_________) __________ -‐ ______________ Cell Phone: (_________) __________ -‐ ______________ Work Phone: (_________) __________ -‐ _______________ Email ________________________________________________ Facebook? Yes No Current Occupation: _________________________________________________________________________________________ Current Employer: __________________________________________________ Start Date: _______ / ______ / _________ EMPLOYMENT/VOLUNTEER INFORMATION Position ____________________________________________ Employer ____________________________________________ Responsibilities: _____________________________________________________________________________________________ _________________________________________________________________________________________________________________ Start Date: _______ / ______ / _________
End Date: _______ / ______ / _________
Position ____________________________________________ Employer ____________________________________________ Responsibilities: _____________________________________________________________________________________________ _________________________________________________________________________________________________________________ Start Date: _______ / ______ / _________
End Date: _______ / ______ / _________
Position ____________________________________________ Employer ____________________________________________ Responsibilities: _____________________________________________________________________________________________ _________________________________________________________________________________________________________________ Start Date: _______ / ______ / _________ June 2010
End Date: _______ / ______ / _________
EDUCATION INFORMATION High School Name of School
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Sports/Activities
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Awards
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Graduation Date:
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College Name of School
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Major/Minor
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Sports/Activities
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Awards
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Graduation Date:
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Degree Earned ______________________________________
Other Name of School
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Degree/Focus
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Sports/Activities
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Awards
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Graduation Date:
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Degree Earned ______________________________________
ADDITIONAL INFORMATION Hobbies and Interests _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ What is one thing you think is a major challenge facing American youth today? _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ June 2010
SPIRITUAL INFORMATION Who is Jesus to you? _________________________________________________________________________________________ _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ Home church ________________________________________________________________________________________________ How long have you attended this church? ___________________ Are you a member? _____ Yes _____ No Please list the name, city, and state of churches you have attended regularly during the past 5 years: _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ Why do you feel called to this position? _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ What are some of your spiritual gifts that you plan to use in your ministry at CPC? _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ What are your vocational goals? _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ Have you worked with youth/children in the past? _______ Yes ______ No Where? ______________________________________________________ In what role? ________________________________ For how long? _________________________ Age groups? _________________________
June 2010
PERSONAL BACKGROUND Have you ever been tried or convicted of child abuse, child molestation, domestic violence or any other crime related to children? ________ Yes ________ No If “Yes” please explain: _____________________________________________________________________________________ Have you ever been convicted of any other criminal charges? ________ Yes ________ No If “Yes” please explain: _____________________________________________________________________________________ PLEASE PROVIDE 3 REFERENCES Name: ______________________________________ Phone (_______) _______ -‐ _____________ Years known: _________ Address/State/Zip: __________________________________________________________________________________________ Relationship to you: _________________________________________________________________________________________ Name: ______________________________________ Phone (_______) _______ -‐ _____________ Years known: _________ Address/State/Zip: __________________________________________________________________________________________ Relationship to you: _________________________________________________________________________________________ Name: ______________________________________ Phone (_______) _______ -‐ _____________ Years known: _________ Address/State/Zip: __________________________________________________________________________________________ Relationship to you: _________________________________________________________________________________________ The information contained in this application is correct to the best of my knowledge. I authorize any reference or churches listed in this application to give you any information (including opinions) that they may have regarding my character and fitness for work with children. In consideration of the receipt and evaluation of this application by Centerville Presbyterian 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 my information provided about me by any person or organization identified by me in this application. Signed: ____________________________________________________ Date: _________ / ___________ / _________________
June 2010