VOLUNTEER SCREENING FORM

FOR STUDENT VOLUNTEERS

This information is confidential. This application must be completed by all applicants under the age of 18 for any position (volunteer or compensated) involving the supervision or custody of minors. It is used to help the church provide a safe and secure environment for children and youth participating in our programs and using our facilities.

PRIMARY SCREENING INFORMATION

For which school year are you applying? *

For which department are you applying? *

For which campus? *

Last Name *

First Name *

Middle Initial *

Birth Date * +

Age *

Grade Now *

Address *

City *

State *

Zip *

Email Address *

Phone Number *

Home phone or cell phone? *

Home

Cell

Parent Last Name (who you live with) *

Parent First Name *

Parent Primary Phone # *

Home / Cell / Work phone? *

Home

Cell

Work

Parent Email *

Please indicate the type of children's or youth work for which you are applying *

Please indicate the date you would be available to begin

What is the minimum length of commitment you can make?

List any abilities, experiences, training, education, or other factors that have prepared you for working with children/youth:

Do you have any physical handicaps or conditions preventing you from performing certain types of activities?

Yes

No

Please explain.

Do you use tobacco? *

Yes

No

Do you drink alcoholic beverages? *

Yes

No

Do you use drugs? *

Yes

No

What kind? *

Prescription

Illegal

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? *

Yes

No

Please explain.

Have you ever been convicted of, or plead guilt to or no contest to any criminal offense of any kind? *

Yes

No

Please explain.

Are you aware of having any traits or tendencies that could pose any threat to children, youth, or others? *

Yes

No

Please explain.

Are you aware of any reason why you should not work with children, youth, or others? *

Yes

No

Please explain.

CHURCH ACTIVITY

Are you a Christian? *

Yes

No

When did you make a decision to follow Christ?

Name of church you regularly attend

Pastor's name

How long have you attended?

Have you ever been given an opportunity to work with children/youth or any other church ministry?

Yes

No

Please explain.

0/20 words

Why do you want to work with children and/or students? *

PERSONAL TESTIMONY

Please tell us about how you became a Christian *

REFERENCE CONTACT INFORMATION

Please use recent references that can speak to your character and abilities with children/youth.

Do not use relatives.

Name of Reference #1 *

Relationship *

Reference #1 Primary Email *

Reference #1 Primary Phone Number

Name of Reference #2 *

Relationship *

Reference #2 Primary Email *

Reference #2 Primary Phone Number

APPLICANT'S STATEMENT, DECLARATION, PERMISSION, AND SIGNATURE

Student Agreement

Should my application be accepted, I agree to follow the policies and procedures of Horizon Community Church.

Date * +

Applicant's Signature * 🛈

clear

Parental Permission

I authorize the references listed in this application to give Horizon Community Church any information (including opinions) that they may have regarding my child’s character and fitness to work with children. I release all such references and Horizon Community Church from any liability for exchanging information or furnishing evaluations, provided it is done in good faith and without malice. I waive any right I have to inspect references made on my child’s behalf.

If my child’s application is accepted, I give my permission for him/her to work with children. I have discussed with the supervising authority any and all situation in which my child has been involved. I understand the requirements and responsibilities for my child to be involved in ministry to minors through Horizon Community Church/Horizon Christian Schools and hereby vouch for my child’s spiritual, emotional, mental, and social ability to volunteer as assigned. I hereby give my support and consent for my child to be involved in the ministry of Horizon Community Church/Horizon Christian Schools and do confirm that all information provided in their application is accurate and true.

Date * +

Parent's Signature * 🛈

clear