Family Ministries Volunteer Application - Centerville Presbyterian Church

Full Legal Name (First, Middle, Last) *

Address *

Phone number *

Please list all other addresses lived in the past 10 years (if same as above, put "same as current address" *

How long have you been attending Centerville Presbyterian Church? *

Are you 18 years or older? *

Yes

No

List previous work, paid or volunteer, involving young people. Please provide the organization and location, type of work, and approximate dates. *

Please share your talents and strengths in working with young people. *

Have you ever been convicted of any criminal offense? *

No

Yes

Have you plead guilty or "no contest" to any criminal offense? *

No

Yes

Have you ever been charged with or convicted of child neglect? *

No

Yes

Have you ever been charged with or convicted of physical or sexual abuse of children or adults? *

No

Yes

Have you plead guilty or "no contest" to any neglect or abuse offense? *

No

Yes

Have any complaints or allegations of misconduct involving children ever been made against you? *

No

Yes

If you answered "yes" to any of the questions 3 through 8, please explain, including in which state the conviction or charge occurred (use the space below, and/or email josh@cpcfremont.org)

Personal References

Please furnish personal references from churches, schools, community, and civic organizations where past work with children was done, if there is no previous work with children, include other volunteer work or activities.

Reference #1 *

Include Name, Telephone Number, Address, Position of person listed, type of work done, and how long have you known this person.

Reference #2 *

Include Name, Telephone Number, Address, Position of person listed, type of work done, and how long have you known this person.

Electronic Signature

I understand that the Child Protection Policy Oversight Group of Centerville Presbyterian Church may contact the references I have provided as part of the process of reviewing this application. I hereby release from any liability any person or organization that provides information. I certify that the information I have provided is true and correct.

Electronic Signature *

Date *