8/9/2019 Power Up Adult Leader App Pastoral Reference

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Potomac CE Power Up Retreat 2015 Adult Registration & Pastor Reference, Page 1 of 2 

Potomac CE Power Up Retreat 2015 Adult Leader Application & Pastoral Reference, Page 1 of 2

APPLICANT’S PERSONAL INFORMATIONFIRST NAME  MIDDLE NAME  LAST NAME 

Name you want on NAME BADGE (“Miss Sue”, “Pastor Jim” etc)  AGE SEX  M F 

E-MAIL ADDRESS An email address is required  for all confirmations and correspondence. 

STREET  ADDRESS (Cannot Use PO Box) 

CITY  ST  ZIP CODE 

DAYTIME PHONE NUMBER (area code + number) home cell work church

EVENING PHONE NUMBER (area code + number) home cell work church

CHURCH CITY  ST 

PRESENT OCCUPATION

Have you previously served at a Potomac District Camp or Retreat? YES NO  When?

Are you certified in/as a Lifeguard CPR EMT LPN RN  Certified in what state?

CHRISTIAN LIFE & MINISTRY

Are you comfortable praying with children?  YES NO

CRIMINAL BACKGROUND INFORMATIONYes No Have you ever been convicted of a criminal offense (excluding traffic tickets)? If YES, explain on separate sheet of paper.Yes No Have you ever been convicted of a child abuse, neglect or molestation? If YES, explain on separate sheet of paperYes No Have you ever been hospitalized for drug or alcohol abuse? If YES, explain on separate sheet of paper.Yes No Do you voluntarily consent to a background check? If NO, we cannot accept you as a chaperone. 

In order to provide a safe and secure environment for students, it is necessary for us to require a background check on all adult leaders.  If you arenot a credentialed A/G minister  or your church does not have a criminal background check on file for you, a current street  address (above) alongwith the following information is required  for us to run a check.

DATE OF BIRTH (mm/dd/yyyy) SS#

ADULT LEADER SIGNATURE OF COMPLIANCEThe information contained in this application is correct to the best of my knowledge. I authorize my pastor to give you any information (including opinions) he/she may have regardingmy character and fitness for children’s ministry. In consideration of the receipt and evaluation of this application by the Potomac District Council, 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 liabilityfor 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 in this application. Should my application be accepted, I agree to be bound by the Constitution and Bylawsand policies of the Potomac District Council of the Assemblies o f God, and to refrain from any unscriptural conduct in the performance of my services on behalf o f the PotomacDistrict Council.

ADULT LEADER’S LEGAL SIGNATURE:

This application is to be completed by all adult leaders attending the retreat. After you have completed in FULL your portion of theapplication, give this form to your pastor for his/her reference. He/she will submit it with your church’s registration.

Do NOTuse

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Duplicate forms as needed; PLEASE DO NOT make back-to-back copies of adult application and pastor reference

8/9/2019 Power Up Adult Leader App Pastoral Reference

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Potomac CE Power Up Retreat 2015 Adult Registration & Pastor Reference, Page 2 of 2 

Potomac CE Power Up Retreat 2015 Adult Leader Application & Pastoral Reference, Page 2 of 2

Reference must be completed by a pastor, staff or board member NOT related to applicant.

PASTOR REFERENCE

NAME OF APPLICANT:

The above-named applicant has given written authorization to obtain from you any information you might have regarding the applicant’s character and fitness forworking with children. The applicant has further released you from liability for any damage that may result from your furnishing us with such an evaluation. Wewould appreciate your complete and confidential answers to the following questions and the return of this form to the Potomac District Christian Education

Department with your church’s registration. The applicant’s registration CANNOT be processed further unless you complete this section. Thank you!REFERENCE QUESTIONS

1. How long have you been acquainted with this applicant?

2. Is he/she a fully devoted follower of Jesus Christ? Yes No If No, explain:

3. What experience in your church does he/she have with children? Explain:

4. Has he/she ever had problems in dealing with children? Yes No If Yes, explain:

5. Is there anything in his/her character that would exempt him/her from working with children? Yes No If Yes, explain:

6. Does he/she have any emotional, mental or physical handicaps that would hinder his/her participation or effectiveness? YesNo If Yes, explain:

7. To your knowledge, has he/she ever been accused of child abuse, neglect or molestation? Yes No If Yes, explain:

8. To your knowledge, has he/she ever been convicted of child abuse, neglect or molestation? Yes No If Yes, explain:

9. To your knowledge, has he/she ever been convicted of a crime (excluding traffic ticket)? Yes No If Yes, explain:

10. Would you trust this person with your own children/grandchildren? Yes No If NOT, explain your reservations:

11. What kind of addition to our district kids ministry do you believe this applicant would be: Excellent Good Fair Poor

BACKGROUND CHECK: Please select ONE  of the following statements

We have completed, and have on file, a criminal background check on this applicant. Date of last check:

This applicant is a credentialed A/G minister.  A background check is on file with his/her A/G credentials application.

We do NOT have a criminal background check on file; a background check must be ordered by the district for this applicant.

PASTOR’S RECOMMENDATION: Please select ONE  of the following statements

I hereby recommend without reservation the above named applicant.

I hereby recommend with reservation the above named applicant. Please explain below.

I hereby CANNOT recommend the above named applicant.

Comments:

PASTOR’S SIGNATURE: Please complete, sign and send this form even if you cannot endorse this applicant. 

Pastor’s Name (Please type or print legibly):

PASTOR’S SIGNATURE:

Do NOTuse

staples

Du licate forms as needed; PLEASE DO NOT make back-to-back co ies of adult a lication and astor reference