White Plains United Methodist Church (WPUMC)

White Plains United Methodist Church (WPUMC)

Volunteer Application

Last Name ______First ______Middle ______

Phone Numbers ______Tshirt Size ______

DO YOU EXPECT TO BE DRIVING IN YOUR CAPACITY AS A VOLUNTEER? _____

Have you at any time ever:

■ Been arrested for any reason?...... □ Yes □ No

■ Been convicted of, or pled guilty or no contest to

any criminal offense of any kind?...... □ Yes □ No

■ Participated in, been accused of, pled guilty or no contest to

any abuse or sexual misconduct?...... □ Yes □ No

Are you aware of:

■ Any traits or tendencies that could pose any threat to

children, youth or other vulnerable persons?...... □Yes □ No

■ Any reason why you should not work with children,

youth, or other vulnerable persons?...... □ Yes □ No

If the answer to any of the above questions is “yes”, please explain in detail on an additional page.

Church Activity:

Please list any church or churches that you have attended regularly in the past five years:

Church Name Pastor’s Name Years attended

______

______

References:

Please list two references (other than relatives) that could speak to your character:

Name/Relationship Address Phone

______

______

If applying to work with children/youth/vulnerable adults, please list any relevant experience: Organization Program Dates Contact

______

______

______

______/___/___

Signature Date: (Month/Day/Year)

First Name ______Middle ______Last ______

Maiden/Other Names ______Years Used ______

Social Security Number ______Date of Birth ____/____/____ (Month/Day/Year)

Driver’s License Number ______State ______Email Address ______
Phone Numbers: (home)______(cell)______(work)______

Please list your addresses within the past seven years (use a separate sheet as needed)

Present Address______

From _____/______/______(Month/Day/Year) To _____/______/______(Month/Day/Year)

Prior Address ______

From _____/______/______(Month/Day/Year) To _____/______/______(Month/Day/Year)

BACKGROUND CHECK DISCLOSURE AND AUTHORIZATION

In the interest of maintaining the safety and security of our members, volunteers, employees, and property, WHITE PLAINS UMC, Inc. (the “Company”) will order a “consumer report” (a background report) on you in connection with your volunteer application, and as you continue to volunteer each year, may order additional background reports on you for security purposes. The background check company, ADP Screening and Selection Services, will prepare the background report for White Plains UMC. ADP Screening and Selection Services is located at 301 Remington Street, Fort Collins, CO, 80524, and can be reached by phone at 800-367-5933 or at their Internet Web site address www.adpselect.com.

The background report may contain information concerning your character, general reputation, personal characteristics, mode of living, etc.. The types of information that may be ordered include but are not limited to:Social Security number verification; criminal, public, educational and, as appropriate, driving records checks; verification of prior employment; reference, licensing and certification checks; and drug testing results. The information may be obtained from private and public record sources, including personal interviews with your associates, friends, and references. You may request more information about the nature and scope of this background report, if any, by telephoning White Plains UMC at (919) 467-9394.

After carefully reading this Background Check Disclosure and Authorization form, I authorize White Plains UMC to order my background report. I understand that the Company may rely on this authorization to order additional background reports, during my tenure as a volunteer without asking me for my authorization again as allowed by law.

I also authorize the following agencies and entities to disclose to ADP Screening and Selection Services and its agents all information about or concerning me, including but not limited to: my past or present employers; learning institutions, including colleges and universities; law enforcement and all other federal, state and local agencies; federal, state and local courts; the military; testing facilities; motor vehicle records agencies; all other private and public sector repositories of information; and any other person, organization, or agency with any information about or concerning me. The information that can be disclosed to ADP Screening and Selection Services and its agents includes, but is not limited to, information concerning my employment history, education, motor vehicle history, criminal history, military service, professional credentials and licenses, and substance abuse testing.

I certify that all of my personal information on this form is true and correct and understand that dishonesty may disqualify me from consideration for volunteering at White Plains UMC.

______/___/___

Signature Date: (Month/Day/Year)

Revised 7/14/17 This document is only accessible to the Business Office personnel who enter information for the background check and Page 1 is kept locked in the Business Office. Page 2 is shredded after the information is entered.