VOLUNTEER & EMPLOYEE
SCREENING FORM

FOR NEW VOLUNTEERS & EMPLOYEES
This information is confidential. This application must be completed by all applicants for any position (volunteer or compensated) involving the supervision or custody of minors. This is not an employment application form. Persons seeking a position in the church or school as a paid employee will be required to complete an employment application in addition to this screening form. It is used to help the church or school provide a safe and secure environment for children and youth participating in our programs and using our facilities.

PRIMARY SCREENING INFORMATION

calendar
Name and grade of student(s) attending HCS (if applicable)
Do you have any physical handicaps or conditions preventing you from performing certain types of activities?
Do you use tobacco? *
Do you drink alcoholic beverages? *
Do you use drugs? *
What kind? *
Have you ever participated in, been accused of, pleaded guilty or no contest to, or been convicted of any form of abuse or sexual misconduct? *
Have you ever been convicted of, or plead guilt to or no contest to any criminal offense of any kind? *
Are you aware of having any traits or tendencies that could pose any threat to children, youth, or others? *
Are you aware of any reason why you should not work with children, youth, or others? *

CHURCH ACTIVITY

Are you a Christian? *
Have you ever been given an opportunity to work with children/youth or any other church ministry?
0/20 words

DRIVER INFORMATION

Do you have a current driver's license? *
calendar
Have you or do you presently hold a commercial driver's license?

Please note that answering yes to any of the following driving questions may prevent you from being a volunteer driver at this time. A review of your record from the Department of Motor Vehicles will be used in our decision making process. This decision typically has no bearing on your being able to volunteer in other capacities. Your driving record will be rechecked periodically and permission to drive may be approved when your driving record is free of convictions that prevent us from granting approval at this time. 

Have you had more than one at-fault accident in the past year, or more than one at-fault accident and one minor moving traffic violation in the past three years? Minor traffic violations include all violations other than those listed as major in questions 3 and 4. *
Have you had more than one minor moving traffic violation in the past year or more than two minor moving traffic violations in the past three years? *
Have you had any major speeding violations in the past two years? Major speeding violations are more than 15 MPH over a posted limit of 45-55 MPH or more than 12 MPH over a posted limit of 40 MPH or lower? *
Have you had a major moving violation in the past three years? The following are included as major moving traffic violations: driving while license is suspended or revoked, driving under the influence (DUI) or driving while intoxicated (DWI), leaving the scene of an accident or incident, reckless operation, improper passing, driving with known or non-inspected defective equipment. *

Requirements for Volunteer Drivers

1. I possess a valid Oregon driver’s license and valid liability insurance coverage as required by state law.
 
2. I understand that I must be 21 years or older to operate my own vehicle and 25 years or older to operate any church vehicles (a CDL is required to operate vehicles with 16 or more passengers.)

3. I understand that in case of any type of accident, injury or vehicle damage, the church’s liability insurance policy does not provide primary or direct insurance on my vehicle. The Church’s insurance shall take effect only after my personal auto, or other insurance that may apply, limits are exhausted.
 
4. I will advise Horizon Community Church of any change in the information provided on this form including, but not limited to, involvement in a car accident in which I am cited, any citations for moving violations, non-renewal of license, change of insurance company, change in amount of insurance coverage, termination of insurance, or change in vehicle.

5. Students riding in my vehicle(s) will be seated in an appropriate front or back seat, never outside of the cab of the vehicle, and will be secured with individual seatbelts in good operating condition (no double belting or cross-belting of passengers is permitted). When required by state or federal law I will have child restraint devices for each child up to 8 years of age or 4’9’’ tall.
 
6. I will carefully transport children and adults, students and school personnel, under my care, including obeying all traffic laws. To my knowledge my vehicle is in safe operating condition.

7. I will notify Horizon Community Church personnel if I no longer wish to drive or if I wish to be removed from the approved volunteer driver list.

REFERENCE CONTACT INFORMATION

Please use recent references that can speak to your character and abilities with children/youth.
Do not use relatives.

APPLICANT'S STATEMENT, DECLARATION, PERMISSION, AND SIGNATURE

My signature below signifies that I agree to each of the following paragraphs:

  1. The information contained in this application is true and 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 or youth work. In consideration of the receipt and evaluation of this application by Horizon Community Church, I hereby release any individual, church, youth organizations, 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 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 and policies of Horizon Community Church, 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 agreement, which I have read and understand.
  2. I certify that I meet all the requirements stated for volunteer drivers.
  3. I give Horizon Community Church permission to conduct, through a vendor or service of its choice, a motor vehicle (driving) record, a criminal history and/or prior employment investigation check to accompany this application. I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.
  4. I certify that the information I have provided herein is accurate and true.
calendar
Signature * 
clear
Secured by Formsite
Horizon Christian School