Confidential Child Worker Form

Full Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

Primary

(###)

###

####

Alternate Phone

Home, Work, etc.

(###)

###

####

Email Address

Date of Birth

YYYY

Current Age

Place of Birth

Marital Status

Spouse's Name

Previous Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Previous Church Memberships

Please list all church memberships and dates of membership for the past 10 years. Please include church name and city/state.

I've regularly attended PBC since...

I joined PBC on...

YYYY

I want to serve the children of PBC because...

PERSONAL REFERENCES

Every person who applies to work with children or vulnerable adults must provide two personal references. If you have been a member of Philadelphia for less than one year, please provide the name of a leader from the church you most recently attended and a person with whom you have worked in the past who knows you well. If you have been a member of Philadelphia for more than one year, please list an elder, deacon, or community group leader who knows you well and another member of Philadelphia who knows you well and can attest to your character. All references must be unrelated to you.

Reference 1

First Name

Last Name

Phone

(###)

###

####

Relationship:

Reference 2

First Name

Last Name

Phone

(###)

###

####

Relationship:

HEALTH INFORMATION

Because of the nature of this ministry, it is essential that we ask the following. Affirmative answers will not automatically disqualify you from ministry.

Do you have any communicable diseases or infections such as TB, Hepatitis B, AIDS, MRSA, etc.?

BACKGROUND INFORMATION

For each of the following, please include location, duration, and in what capacity you served.

Please list your previous church-related work involving children

Please list all previous non-church-related work involving children

Please describe any training, education, or other factors (including medical or musical training) that would apply to your ministry to children

PERSONAL HISTORY CONCERNS

The following questions are designed to help us provide a safe, loving, and secure environment for all volunteers and children. All information provided in this section of the application will be treated confidentially and will not be disclosed unless the elders deem it necessary for the protection of the children participating in our programs. If any of the following questions is answered "yes," an elder will talk with you in private to determine whether pastoral assistance or counseling may be needed and to learn whether that issue has a bearing on your ability to work with children. Answering "yes" to any of these questions will not necessarily disqualify you from participation in children's ministry at Philadelphia. If you prefer not to answer in writing any of these questions please mark "I would like to discuss this," and an elder will speak with you personally and privately.

Have you ever been accused of, participated in, plead guilty to, or been convicted of child abuse, child neglect, or any other crime against a minor?

As a teenager or as an adult, have you ever touched a child in a sexual or abusive manner?

In the past year have you deliberately and repeatedly viewed pornography at all?

This includes reading, watching, listening to, or in any other way using pornographic material including books, magazines, television, movies, the Internet, or telephone services.

Have you ever viewed or participated in violent pornography?

Have you ever viewed or participated in child pornography?

Have you ever been involved in the production or distribution of pornography of any type?

Have you ever participated in homosexual conduct?

Have you ever been arrested, convicted, or plead guilty to a crime other than minor traffic violations?

AUTHORIZATION FOR CRIMINAL RECORDS CHECK

I hereby request and authorize the release of information which pertains to any record of convictions contained in the law enforcement files maintained on me whether local, state, or national. I hereby release local, state, and national law enforcement agencies from any liability resulting from such disclosure.

Note: Any reported felony or misdemeanor will be discussed with you and the elders and may be grounds for denial of application to work with children.

Full Name

First Middle Last

Maiden Name or Aliases

Driver's License Number

Driver's License State of Issuance

Social Security Number

APPLICANT'S STATEMENT

By clicking the SUBMIT button below, I certify that the information contained in this application is true and correct to the best of my knowledge. I authorize Philadelphia Baptist Church to contact any references or organizations listed in this application. Furthermore, I authorize such references and organizations to provide Philadelphia Baptist Church with any information they may have regarding my character and fitness for working with children. I release Philadelphia Baptist Church, all of its agents, and all such references and organizations from any and all liability for any damage that may result from furnishing such evaluations to you, and I waive any right that I may have to inspect references provided on my behalf. I further state that I have carefully read the foregoing release and know and understand the contents thereof. I agree to this release as my own free act. This is a legally binding agreement that I have read and understand.