Area of service Office use only

(This form is required every 2 years)

Our church cares about the children and youth in our programs, and desires to ensure their safety while they are in the church’s supervision. Because we care for children and youth, our church asks any volunteer who will be providing supervision/leadership with minors to complete this disclosure form. The information obtained on this form is for internal use by Church of the Resurrection only. Please answer each question below. Your social security number is required. Your responses will be treated confidentially.

Name (Include Middle Initial) ______________________________ Date of Birth (M/D/Y) ____________________ List Any Other Names Used ____________________________________________________________________ Address (Include City, State and Zip) ______________________________________________________________ List previous Addresses (last 10 years) ____________________________________________________________ ___________________________________________________________________________________________ Social Security Number ____________________ Email Address _________________________________________ Home Telephone ___________________ Business or Cell phone ________________________________________ Occupation and Current Employer _________________________________________________________________ As a volunteer in KiDS COR, do you agree to observe all church policies regarding working with minors? _____Yes Have you ever been convicted of a criminal offense? ______________________________________________ Yes Do you have any criminal charges pending? _____________________________________________________Yes Have you ever been convicted of child neglect or abuse? ___________________________________________Yes Do you have any charges of child neglect or abuse pending? ________________________________________Yes In addition to the above, is there any fact or circumstances involving you or your background that would call into question you being entrusted with the supervision, guidance, and care of children or young people? ____ Yes (If yes, explain in detail on a separate page, including dates and locations) Do you have a driver’s license? Yes No List the state and driver’s license number _____________________ No No No No No No

List two references, other than family members, who are familiar with your character as it relates to working with minors. (Name/Address/Telephone Number/Relationship) 1.__________________________________________________________________________________________ 2.__________________________________________________________________________________________ List the churches you have attended regularly for the last several years. (Name and Location) ___________________________________________________________________________________________ ___________________________________________________________________________________________ List all organizations through which you have volunteered with minors in the past 5 years. (Include Location) ___________________________________________________________________________________________ ___________________________________________________________________________________________
The information that I have provided may be verified by contacting persons named in this application, or by contacting any person or organization that may have any information concerning me. I hereby release and agree to hold harmless from liability any person or organization that provides information. I also agree to hold harmless the Church of the Resurrection, and its paid staff members and volunteers. I waive any right to inspect any information provided about me by any person, organization, or investigative agency. In signing this application, I agree to be guided by the policies and regulations of Church of the Resurrection. I affirm that the information I have given on this form is true, correct and complete.

The Church of the Resurrection is unaware of any information contrary to the information stated on this application. Action Taken _____________

____________________________________________________________ Signature of Applicant Date Please complete the reverse side of this application.

Approved by _____________ Date ___________________ Member ____ Lanyard _____ Entered in Arena _____

Revised 7/2010

Have you volunteered within Children’s Ministries before? Yes


If yes, what was your most recent date of participation?__________________________ Do you have a KiDS COR lanyard/name tag? Yes No

If no, how do you want your name to read on your KiDS COR lanyard/name tag?

Where are you serving? (Please circle area and time if listed) • • • • • • • • • • • • • • • • • • • • • • • • • Saturday Evening Nursery (Infant – Age 2) Saturday Evening Early Childhood Guide (Age 2-Pre-K) Sunday Evening Nursery (Infant – Age 2) Sunday Evening Early Childhood Guide (Age 2 - Pre-K) Sunday Evening (K – 5th Grade) Sunday Morning Nursery (infant-Age 2) 9:00 or 10:45 Sunday Morning Early Childhood Guide (Age 2-Pre-K) 9:00 or 10:45 Sunday Morning Elementary Guide (K-5th Grade) 9:00 or 10:45 Information Booth Sat. 5 Sun. 9:00 or 10:45 Sun. 5 Greeter Sat. 5 Sun. 9:00 or 10:45 Sun. 5 Drama Team Sat. 5 Sun. 9:00 or 10:45 Sun. 5 Sound Booth Sat. 5 Sun. 9:00 or 10:45 Sun. 5 Music Team Sat. 5 Sun. 9:00 or 10:45 Sun. 5 Parent helper Sat. 5 Sun. 9:00 or 10:45 Sun. 5 Summer Classroom Helper Sat. 5 Sun. 9:00 or 10:45 Sun. 5 Christmas Eve Nursery Easter Nursery Special events – Family Advent Night 3rd Grade Bible VBC Youthfront ZONE W.I.L.D. 1s Summer Sports Camp Bin Babe Photographer or Filming Puppets Library

Please return this form to your program director or a KiDS COR Ministry Connector: Stacy Furey 232-4194 or Fax: 544-0799
Revised 7/2010