Form A - Employment Application Form
Form B -
Reference Contact Form
Form C - Background
Investigation Consent Form
Form
D - Volunteer Application Form
Form E -
Notification Of Ineligibility Form
Form
F - Visiting Organization Form
Form G -
Report Of Suspected Incident Of Child Sexual Abuse Form
Employment Application Form (Form
A)
(Confidential Upon Completion)
Name:
____________________________________________________________________
Last First Middle
Are you
over the age of 18? _____ Yes _____
No
Present
address: ____________________________________________________________
City:
______________________________
State: ____________ Zip: __________________
Home Phone:
______________________________________________________________
Position
applied for: ___________________________ Date available to start: ____________
Qualifications:
Academic
achievements: (Schools attended, degrees earned, dates of completion)
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Continuing
education completed: (Courses taken, dates of completion)
______________________________________________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________
Professional
organizations: (List any in which you have membership)
______________________________________________________________________________________________________________________________________________________________________________________________________________________________
First aid
training? ____ Yes ____ No Date
completed: __________________________
CPR
training? ____ Yes ____
No Date
completed: __________________________
Previous
Work Experience: Please
list your previous employers during the past five years. Include the job title, a description of
position, duties and responsibilities, the name of the company/employer, the
address of company/employer, the name of your immediate supervisor, and the
dates you were employed in each position.
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________________________________________________________________________
Previous
Volunteer Experience: Please list any relevant volunteer positions you have held and list the
duties you performed in each position, the name of your supervisor, the address
and phone number of the volunteer organization, and the dates of your volunteer
service.
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Have you
ever been convicted of or pled guilty to a crime, either a misdemeanor or a
felony (including but not limited to drug-related charges, child sexual abuse,
other crimes of violence, theft, or motor vehicle violations)? _______ No ________ Yes
If yes,
please explain:
____________________________________________________________________________________________________________________________________________________
References:
Please list three
individuals who are not related to you by blood or marriage as references.
1. Name:
_______________________________________________________________
Address:
_____________________________________________________________
Day
Phone: _______________________ Evening Phone: ______________________
Length
of time you have known reference: ___________________________________
Relationship
to reference: ________________________________________________
2. Name:
_______________________________________________________________
Address:
_____________________________________________________________
Day
Phone: _______________________ Evening Phone: ______________________
Length
of time you have known reference: ___________________________________
Relationship
to reference: ________________________________________________
3. Name:
_______________________________________________________________
Address:
_____________________________________________________________
Day
Phone: _______________________ Evening Phone: ______________________
Length
of time you have known reference: ___________________________________
Relationship
to reference: ________________________________________________
(Employment Application Form (Form A)
page 2)
Reference Contact Form (Form B)
(Confidential Upon Completion)
Applicant
name: _____________________________________________________________
Reference
Name: ____________________________________________________________
Reference
Address: __________________________________________________________
Reference
Phone: ___________________________________________________________
1. What is your relationship to the
applicant?
2. How long have you known the applicant?
3. How well do you know the applicant?
4. How would you describe the applicant?
5. How would you describe the applicantÕs
ability to relate to children?
6. How would you describe the applicantÕs
ability to relate to adults?
7. How would you describe the applicantÕs
leadership abilities?
8. Do you know of any characteristics that
would negatively affect the applicantÕs ability to
work with children? If so, please describe.
9. Please list any other comments you
would like to make.
Reference
inquiry completed by: ________________________________________________
Signature Date
Background Investigation Consent
Form (Form C)
(Confidential Upon Completion)
I,
__________________________________, hereby authorize Peace Lutheran Church and
its agents to make an independent investigation of my background, references,
character, past employment, 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 now and, if applicable, during the tenure of my employment with
Peace Lutheran Church.
I release
Peace Lutheran Church and/or its agents and any person or entity, which
provides information pursuant to this authorization, from any and all
liabilities, claims or law suits in regards to the information obtained from
any and all of the above referenced sources used.
The
following is my true and complete legal name and all information is true and
correct to the best of my knowledge:
__________________________________________________________________________
Full
Name (Printed)
__________________________________________________________________________ Maiden
Name or Other Names Used
__________________________________________________________________________
Present
Address How
Long?
_________________________________________________________________________
City/State Zip
__________________________________________________________________________
Former
Address How
Long?
__________________________________________________________________________
City/State Zip
______________ ___________________ ___________________ ___________
Date of Birth Social
Security Number DriverÕs
License Number State
of Issue
__________________________________________________________________________
Signature
Note: The above information is required for
identification purposes only, and is in no manner used as qualifications for
employment.
Volunteer Application Form (Form
D)
(Confidential Upon Completion)
Name:
_____________________________________________________________________
Address:
___________________________________________________________________
Day phone:
______________________________ Evening
phone: _____________________
Occupation:
______________________________ Employer: _________________________
Previous
volunteer experience with children: _______________________________________
____________________________________________________________________________________________________________________________________________________
Special
interests/hobbies/skills: _________________________________________________
Why would
you like to volunteer to work with children? _______________________________
____________________________________________________________________________________________________________________________________________________
What
qualities do you have that would help you work with children?
____________________ ____________________________________________________________________________________________________________________________________________________
Have you
ever been charged, convicted of, or pled guilty to a crime, either a
misdemeanor or a felony (drug-related charges, child sexual abuse, or other
crimes of violence)?
______ No ____ Yes If yes, please explain:
____________________________________________________________________________________________________________________________________________________
References:
Please list three
personal references (people who are not related to you by blood or marriage)
and provide a complete address and phone information for each.
1. Name:
_______________________________________________________________
Address:
_____________________________________________________________
Day
Phone: _______________________ Evening Phone: ______________________
Relationship
to reference: ________________________________________________
2. Name:
_______________________________________________________________
Address:
_____________________________________________________________
Day
Phone: _______________________ Evening Phone: ______________________
Relationship
to reference: ________________________________________________
3. Name:
_______________________________________________________________
Address:
_____________________________________________________________
Day
Phone: _______________________ Evening Phone: ______________________
Relationship
to reference: ________________________________________________
Signature:
_________________________________________ Date: ____________________
Notification of Ineligibility
Form (Form E)
(Confidential Upon Completion)
ApplicantÕs
name: ____________________________________________________________
Date
notified: _______________________________________________________________
Reason for
ineligibility:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Signature
Parish Relations Ministry Representative Date
__________________________________________________________________________
Signature
Applicant Date
Visiting Organization Form (Form
F)
Peace Lutheran Church encourages the
use of its facility by visiting organizations and opens its doors to
organizations which need space for events involving children. To ensure the
safety of all children, Peace Lutheran Church requires that visiting leaders
abide by the Child Safety Governing Policy.
Name of
Organization: ________________________________________________________
Date(s)
facility will be used: ____________________________________________________
Anticipated
number of participants: Children __________ Adults
__________
We hereby
acknowledge that we have reviewed this copy of Peace Lutheran ChurchÕs Child
Safety Governing Policy, Procedures, Forms, and Training Materials. We agree to provide a minimum of two
adults for the duration of time that our organization uses Peace Lutheran
ChurchÕs facility.
__________________________________________________________________________
Print Name
of Visiting Adult Participant # 1 Signature
Date
__________________________________________________________________________
Print Name
of Visiting Adult Participant # 2 Signature Date
__________________________________________________________________________
Signature
Church Secretary Peace Lutheran Church
Date
The Church
Secretary will retain this original document on file in the church office. A copy may be provided to the visiting
organization if requested.
Report of Suspected Incident of
Child Sexual Abuse Form (Form G)
1. Name of person observing or receiving
disclosure of child
sexual abuse: _____________________________________________
2. VictimÕs name: ________________________
VictimÕs age/date of birth: _______________
3. Date and place of initial conversation
with/report from victim: ________________________
________________________________________________________________________
4. VictimÕs statement (give your detailed
summary here): _____________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
5. Name of person accused of abuse:
____________________________________________
6. Relationship of accused to victim (paid
staff, volunteer, family member, other):
_______________________________________________________________________
7. Date and time of report to Polk County
Human Services: ___________________________
Person spoken with:
_______________________________________________________
Summary of
conversation:___________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
8. Date and time of report to Parish
Relations Ministry Chairperson: ____________________
Date and time of
report to Senior Pastor: _______________________________________
Date and time of
report to Church Council President: ______________________________
9. Date and time of report to victimÕs
parent/guardian: _______________________________
Summary of
conversation: __________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Signature of
Person Making Report Date