CENTERVILLE PRESBYTERIAN CHURCH
YOUTH/CHILDRENS WORKER APPLICATION In compliance with San Francisco Presbytery, this application is to be completed by all applicants for any position – volunteer or compensated – involving the supervision or custody of minors. It is being used to help provide a safe and secure environment for the children and adults who participate in our programs and use our facilities. It will be kept safe completely confidential and will be locked in our personnel file. It will be used only by the leadership of Centerville Presbyterian Church regarding church work. PLEASE COMPLETE ALL PAGES OF THIS APPLICATION BASIC INFORMATION First Name: ____________________________
Last Name: ________________________________
Social Security #: ________ - _______ - _____________
M.I. ___________
Date of Birth: ________ / _________ / __________
Other names used: ___________________________________________________________________________________________ Address: ________________________________________________________ Home Phone: (_________) __________ - ______________
City: _________________ Zip: _____________
Cell Phone: (_________) __________ - ______________
Work Phone: (_________) __________ - _______________ Marital Status: ____ Single _____ Engaged _____ Married _____Widowed ____ Separated _____Divorced Occupation: __________________________________________________________________________________________________ Your Employer: _____________________________________________________ Start Date: _______ / ______ / _________ Spouse’s Name: _______________________________________________
Occupation: __________________________
Spouse’s Employer: ______________________________________________ Work Phone: (_______) _______ - _________ Names and Ages of Children _________________________________________
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Do you have any physical handicaps or conditions that would prevent you from performing certain types of activities? ________ Yes ________ No If yes, please explain________________________ _________________________________________________________________________________________________________________ Emergency Contact Person: _______________________________________ Phone: (________) _______ - ___________
June 2009
SPIRITUAL INVENTORY Who is Jesus to you? _________________________________________________________________________________________ _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ How long have you attended CPC? _______________________ Are you a member? ______ Yes ________ No Home church (if not CPC) ___________________________________________________________________________________ Please list the name, city, and state of churches you have attended regularly during the past 5 years: _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ Why do you want to work with the youth/children at CPC? _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ 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? _________________________
Reference Contact: ___________________________________________________________________________________________
June 2009
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. I understand that Centerville Presbyterian Church provides insurance coverage for all churchsponsored activities. This insurance is secondary to my own insurance coverage, which is agreed as being primary. If I am uninsured and in the event of an injury to me with a claim against the church’s insurance carrier, I agree to cover the deductable cost required by the insurance carrier. Signed: ____________________________________________________ Date: _________ / ___________ / _________________ June 2009