Primary Screening Form for Children Or Youth Work

CONFIDENTIAL

GRACEEVANGELICALCHURCH

Indianapolis, Indiana

Primary Screening Form for Children or Youth Work

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. This form 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. All who work with our children as a teacher or assistant are asked to provide this information; you are not being singled out for closer inspection.

PERSONAL INFORMATION

Date: ______

Name: ______

Last First Middle

Present address: ______

City: ______

State: ____ Zip: ______Home Phone ( ) ______

Cell Phone ( ) ______

E-mail Address: ______

Are you a member of GraceEvangelicalChurch? Yes No

Are you in an Adult Bible Fellowship? Yes Which one?______No

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? ______

MINISTRY INFORMATION

List (name and address) other churches you have attended regularly during the past five years: ______

List all previous church work involving youth (list each church’s name and address, type of work performed and dates) ______

List all previous non-church work involving youth (list each organization’s name and address, type of work performed and dates) ______

List any gifts, callings, training, education or other factors that have prepared you for children or youth work: ______

Personal testimony: (When you accepted Christ as your personal Savior)

______

THREE PERSONAL REFERENCES (not a relative)

1st Reference (Co-worker or friend)Name: ______

Address: ______City:______ZIP:______

Email: ______DaytimeTelephone: ______

2nd Reference (Fellowship Group Leader)Name: ______

(List your Fellowship Group Leader if in a group; if not in a group use a non-relative)

Address: ______City:______ZIP:______

Email: ______Daytime Telephone: ______

3rd Reference for non-members (FormerChurch Leader) Name: ______

(If NOTa member of a previous church, list your former church’s pastor or someone who oversaw a ministry you were involved in)

Address: ______City:______ZIP:______

Email: ______Daytime Telephone: ______

Name of Church: ______Person’s Position at church: ______

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 child or youth work. In this consideration of the receipt and evaluation of this application by Grace Evangelical 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 be bound by the GEC Constitution and policies of GraceEvangelicalChurch, and 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 FOREGOING RELEASE AND KNOW THE CONTENTS THEREOF AND I SIGN THIS RELEASE OF MY OWN FREE WILL.

Applicant’s Signature: ______Date:______

REQUEST FOR BACKGROUND CHECK

AND AUTHORIZATION

I, ______, hereby authorize you to release to Grace Evangelical Church of Indianapolis, Indiana, any information which pertains to any record of convictions contained in your files or in any criminal file maintained on me whether local, state or national. I hereby release said Police Department from any and all liability resulting from such disclosure. A photocopy of this authorization shall be as valid and binding as the original.

______

Signature Print name

______

Print maiden name if applicable Print all aliases

______

Date of birth Social Security Number

LEGAL INFORMATION

Conviction of a Crime is not an automatic bar to a teaching or an administrative position in our church. Our Elder Board will consider the nature of the offense and the relationship between the offense and the position for which you are applying. Any false or misleading information on this application shall be fully sufficient grounds for immediate removal from a position.

Are you presently being investigated-or under a procedure to consider your discharge for misconduct by your present employer, or have you offered to resign due to such an investigation?  Yes  No

Have you ever been reprimanded, disciplined, discharged, or asked to resign from a prior position?  Yes  No

Have you every resigned from a prior position without being asked, but under circumstances involving your employer’s investigation of sexual contact with another person, of mishandling of funds, or of criminal conduct?  Yes  No

(If you have answered yes to any one of the previous three questions, explain the circumstances on a separate sheet and attach it to this application.)

Have you ever been charged with or investigated for sexual abuse of another person?

 Yes  No

Have you ever been charged with, pleaded guilty or “no contest” to, or been convicted of any crime involving sexual abuse or any other crime of moral turpitude?  Yes  No

Have you a) ever been convicted of a crime, other than a minor traffic offense; or b) ever entered a plea of guilty or a plea of “no contest” , or has any court ever deferred further proceedings without entering a finding of guilty and placed you on probation, for any crime other than a minor traffic offense?  Yes  No

(If you have answered yes to any one of the previous three questions, please explain, in detail, including the date of the charge, the court action, the offense in question, and the address of the court involved.)

My signature below constitutes authorization to check my employment history, including without limitation, evaluation, criminal arrest and conviction record checks, reference checks, and release of investigatory information possessed by any private or public employer or any state, local or federal agency. I further authorize those persons, agencies or entities that the Grace Evangelical Church Board of Elders contacts in connection with my employment application to fully provide the Grace Evangelical Church Board of Elders any information on the matters set forth above. I expressly waive in connection with any request for or provision of such information, any claims, including without limitation, defamation, emotional distress, invasion of privacy, or interference with contractual relations that I might otherwise have against the Grace Evangelical Church Board of Elders, its agents and officials or against any provider of such information.

Signature: ______Date: ______

Revised 9/10/08