CENTERVILLE PRESBYTERIAN CHURCHYOUTH/CHILDRENS WORKER APPLICATION

In compliance with San Francisco Presbytery, 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 provide a safe and secure environment for the children and adults who participate in our programs and use our facilities. It will be kept safe completely confidential and will be locked in our personnel file. It will be used only by the leadership of Centerville Presbyterian Church regarding church work.

PLEASE COMPLETE ALL PAGES OF THIS APPLICATION

BASIC INFORMATION

First Name: ____________________________ Last Name: ________________________________ M.I. ___________

Social Security #: ________ - _______ - _____________ Date of Birth: ________ / _________ / __________

Other names used: ___________________________________________________________________________________________

Address: ________________________________________________________ City: _________________ Zip: _____________

Home Phone: (_________) __________ - ______________ Cell Phone: (_________) __________ - ______________

Work Phone: (_________) __________ - _______________

Marital Status: ____ Single _____ Engaged _____ Married _____Widowed ____ Separated _____Divorced

Occupation: __________________________________________________________________________________________________

Your Employer: _____________________________________________________ Start Date: _______ / ______ / _________

Spouse’s Name: _______________________________________________ Occupation: __________________________

Spouse’s Employer: ______________________________________________ Work Phone: (_______) _______ - _________

Names and Ages of Children

_________________________________________ _________ _____________________________________ _________

_________________________________________ _________ _____________________________________ _________

Do you have any physical handicaps or conditions that would prevent you from performing

certain types of activities? ________ Yes ________ No If yes, please explain________________________

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Emergency Contact Person: _______________________________________ Phone: (________) _______ - ___________

June 2009

SPIRITUAL INVENTORY

Who is Jesus to you? _________________________________________________________________________________________

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How long have you attended CPC? _______________________ Are you a member? ______ Yes ________ No

Home church (if not CPC) ___________________________________________________________________________________

Please list the name, city, and state of churches you have attended regularly during the past 5

years:

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Why do you want to work with the youth/children at CPC?

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What are some of your spiritual gifts that you plan to use in your ministry at CPC?

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What are your vocational goals?

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Have you worked with youth/children in the past? _______ Yes ______ No

Where? ______________________________________________________ In what role? ________________________________

For how long? _________________________ Age groups? _________________________

Reference Contact: ___________________________________________________________________________________________

June 2009

PERSONAL BACKGROUND

Have you ever been tried or convicted of child abuse, child molestation, domestic violence or any

other crime related to children? ________ Yes ________ No

If “Yes” please explain: _____________________________________________________________________________________

Have you ever been convicted of any other criminal charges? ________ Yes ________ No

If “Yes” please explain: _____________________________________________________________________________________

PLEASE PROVIDE 3 REFERENCES

Name: ______________________________________ Phone (_______) _______ - _____________ Years known: _________

Address/State/Zip: __________________________________________________________________________________________

Relationship to you: _________________________________________________________________________________________

Name: ______________________________________ Phone (_______) _______ - _____________ Years known: _________

Address/State/Zip: __________________________________________________________________________________________

Relationship to you: _________________________________________________________________________________________

Name: ______________________________________ Phone (_______) _______ - _____________ Years known: _________

Address/State/Zip: __________________________________________________________________________________________

Relationship to you: _________________________________________________________________________________________

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 work with children. In consideration of the receipt and evaluation of this application by Centerville Presbyterian 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 my information provided about me by any person or organization identified by me in this application.

I understand that Centerville Presbyterian Church provides insurance coverage for all church-sponsored activities. This insurance is secondary to my own insurance coverage, which is agreed as being primary. If I am uninsured and in the event of an injury to me with a claim against the church’s insurance carrier, I agree to cover the deductable cost required by the insurance carrier.

Signed: ____________________________________________________ Date: _________ / ___________ / _________________

June 2009