APPLICATION FOR CHILDREN & YOUTH WORKERS AND

BACKGROUND INFORMATION CONSENT FORM
               FIRST APOSTOLIC CHURCH, INC.

CONFIDENTIAL

Office Use Only

Department: ________________________________				Pastor: ___________________________

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 the church provide a safe and secure environment for those children and youth who participate in our programs and use our facilities.

* Identity must be confirmed with a state driver’s license or other photographic identification (attach copy).

Legal Name: ________________________________________________________________________________________

Last	First	Middle

Maiden Name or other names used: _________________________________________________________

Present Address: __________________________________________________________________________

City: _________________________ State: _______________________  Zip: _________________________

How long at present address? ________________________________________________________________

Home Phone: _____________   Cell phone: _____________ Email: _________________________________

Former Address: ____________________________________________________________________

City:				 State:				   Zip:				
How long at former address? 				
If less than 5 years at resident, please provide former counties and states of residence:																	
Date of Birth:				   Place of Birth:							
Social Security#:		-		-		
Driver’s License#:				   State of License Issued:					

The above information is required for identification purposes only and is in no manner used as qualification for employment. 
First Apostolic Church, Inc. abides by all applicable state and federal employment laws.

Have you ever been convicted of child abuse or a crime involving actual or attempted sexual molestation of a minor?  YES      NO

If yes, please explain (attach a separate page if necessary): ____________________________________

___________________________________________________________________________________

Were you a victim of abuse or molestation while a minor?   YES          NO       UNSURE

If you prefer, you may discuss your answer to this question with the Senior Pastor rather than answering it on the form. Answering yes, or leaving the question unanswered, will not automatically disqualify an applicant for work.

Have you ever been convicted of, been accused of or practiced homosexuality?   YES      NO

If yes, please explain (Attach a separate page if necessary): _________________________________

_________________________________________________________________________________

Have you ever been convicted of a criminal offense?  YES      NO       If yes, please explain (Attach a separate page if necessary): _____________________________________________________

_________________________________________________________________________________

NAME:             ________________________

CHURCH ACTIVITY

Name of church where you are a member: _______________________________________________

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

_________________________________________________________________________________

_________________________________________________________________________________

List all previous work involving children/youth.  Identify the church and the type of work:

_________________________________________________________________________________

_________________________________________________________________________________

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

What type of children/youth work do you prefer? __________________________________________ 

Within the area of ministry where do you feel the best place for you would be?

 Leading Volunteers   Teaching Children    Assisting Teachers    Greeting   Hospitality 
 Other: ____________________________________________________________________________ 

When and how often are you available to serve?

  Wednesday 7:00   Sunday 8:00  Sunday 9:00  Sunday 11:00  Morning Worship Service  Other: 
________________________________________________________________________________________________

Minimum length of commitment? ___________________________________________________________

*No volunteer should be considered for any position involving contact with children or youth until the candidate has been involved with this church for one (1) year (unless authorized by Senior Pastor).  You may begin the application process after nine (9) months of regular attendance at the church.

PERSONAL REFERENCES

Name: ______________________________________________________________________________

Address: ____________________________________________________________________________

City, State & Zip: _____________________________________________________________________

Telephone: __________________________________________________________________________

Name: ______________________________________________________________________________

Address: ____________________________________________________________________________

City, State & Zip: _____________________________________________________________________

Telephone: __________________________________________________________________________

Name: ______________________________________________________________________________

Address: ____________________________________________________________________________

City, State & Zip: _____________________________________________________________________

Telephone: __________________________________________________________________________

BACKGROUND INFORMATION CONSENT FORM
                                      APPLICANT AUTHORIZATION AND RELEASE FORM

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 opinions that they may have regarding my character and fitness for children/youth work. In consideration of the receipt and evaluation of this application by the First Apostolic Church, Inc., I hereby release any individual, church, youth organization, charity, employer, reference, or any other organization, including record custodians, agents and representatives, both collectively and individually, from any 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 bylaws, policies and practices of First Apostolic Church, Inc., 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 AS MY OWN FREE ACT. THIS IS A LEGALLY BINDING AGEEMENT THAT I HAVE READ AND UNDERSTAND.

I also hereby authorize of First Apostolic Church, Inc. and/or its agents or representatives to make an independent investigation of my background, references, character, past employment, education, credit history, criminal or police records, including those maintained by both public and private organizations and all public records for the purpose of confirming the information contained on my application and/or obtaining other information which may be material to my qualifications for employment/service (volunteer) now and, if applicable, during the tenure of my employment/service (volunteer) with of First Apostolic Church, Inc.

These above-mentioned background information checks may include, but are not limited to, employment and education verifications, social security verification, driving record information, personal references, personal interviews and personal credit history. I further understand that an acceptable credit report and/or background check will allow me to continue the pre-employment/service process and that an unacceptable credit and/or background check may result in the discontinuation of my pre-employment/service (volunteer) process. I understand if I am hired or permitted to serve (volunteer) prior to the completion of the background check that an unacceptable background check will result in my termination.

I understand that I am entitled to a complete and accurate disclosure of the nature and scope of any criminal background search prepared on me upon written request within a reasonable time after the date of such search.

I further authorize any person, business entity or governmental agency who may have information relevant to the above to disclose the same to First Apostolic Church, Inc. including but not limited to any courthouse, any public agency and all law enforcement agencies and any and all credit bureaus regardless of whether such person, business entity or governmental agency compiled the information itself or received it from other sources.

I release First Apostolic Church, Inc. and/or its agents or representatives and any persons, business entities and governmental agencies, whether public or private, from any and all liability, claims and/or demands, of whatever kind, by me, my heirs and others making such claim or demand on my behalf, for procuring, selling, providing, brokering and/or assisting with compilation or preparation of the background information check hereby authorized.

Printed Name in Full

Applicant’s Signature							Date

Witness’s Signature							            Date

REPORTING PROCEDURES FOR
CHURCH WORKERS

Each teacher involved in the Youth/Children’s Ministry should report any suspicious behavior or comments that would lead an individual to believe that PHYSICAL ABUSE AND/OR SEXUAL ABUSE has occurred. The following are indications of possible abuse:

♦ PHYSICAL SIGNS - lacerations and bruises, nightmares, irritation, pain or injury to genital area, difficulty with urinating, discomfort when sitting, torn or bleeding underclothing, venereal disease

♦ BEHAVIORAL SIGNS - anxiety when approaching church or nursery area, nervous or hostile behavior toward adults, sexual self-consciousness, “acting out” sexual behavior, withdrawal from church activities

♦ VERBAL SIGNS - I don’t like (particular church worker), (a church worker) does things to me when we’re alone, I don’t like to be alone with (a church worker), (a church worker) fooled around with me.

If any of these things should take place, a teacher must report what they have seen or heard to the person directly over their department. The department head will then relay that information to the Senior Pastor. If, in the judgment of the Senior Pastor, there is any truth to the allegations, he/she will report these findings to the appropriate state agency within 24 hours. The Senior Pastor may file the report anonymously from the office of an independent third party (such as the church’s attorney) if he/she chooses.

On a periodic basis there will be meetings to discuss reporting procedures. Everyone involved will know the responsibility that they have to report incidents. If the department you are serving has a policy and procedural manual you are required to read and sign any statement of agreement.

APPLICANT’S STATEMENT

I have read, understand and agree to comply with these reporting procedures.

	
Signature                                                                      Date

DISCLAIMER

This material is provided for general information purposes only and does not constitute professional advice.  It is a generic document that is not specifically designed for your organization. We have provided it as a matter of professional courtesy for you to consider, together with your legal counsel, as you determine what is appropriate for your organization. In establishing your organization’s policies or procedures for the purpose of governance documents, you should consider, together with your legal counsel, your unique operational, financial and legal circumstances. No recipients of this information should act or refrain from acting solely on the basis of this material without seeking professional legal counsel. The Pentecostal Assemblies of the World, Inc., National Church and Clergy Management Assistance Corporation, Clergyzoom and all of its partners expressly disclaim all liability relating to actions taken or not taken based solely on the content of this material.
For more information or professional assistance with church or para-church matters, please contact: Dr. Wyatt McDowell (JD, LLM) at (740) 938-4067.