Background Screening Form

This application is to be completed by all applicants for any volunteer positions involved in the safety, supervision, and security of adults, minors, and church offerings. This form is being used to help the church provide a safe and secure environment for all adults and minors who participate in our programs and use our facilities.

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1Personal Information > 2Church History/Ministry Experience > 3Applicant's Statement
Date Date / MM / DD YYYY
Name Name First Middle Last
List Maiden Name (or any name used, including previous marriage):
What ministry will you be serving in?
(You must have been prescreened by the ministry leader before submitting this form)

What ministry will you be serving in?
(You must have been prescreened by the ministry leader before submitting this form) Children's Ministry Puente de Vida Kids (Midway ONLY) Youth Ministry Awana Security Team Offering/Counting Team
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Previous Address (If not applicable type in N/A) Previous Address (If not applicable type in N/A)
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Home Phone Home Phone - ### - ### ####
Cell Phone Cell Phone - ### - ### ####
Email
Birth Date Birth Date / MM / DD YYYY
Social Security Number
Do you have a current driver's license?

Do you have a current driver's license? Yes No
Driver's License Number (If no type in N/A)
Have you ever been convicted of, or pled guilty to a crime?

Have you ever been convicted of, or pled guilty to a crime? Yes No
If yes, please explain. (If no type in N/A)
NOTE: The following question applies only to those serving with or around youth and children.

If you prefer, you may refuse to answer the following question, or you may discuss your answer in confidence with the senior pastor rather than answering it on this form. Answering yes or leaving the question unanswered, will not automatically disqualify an applicant for youth or children's work.

Were you a victim of abuse or molestation while a minor?

NOTE: The following question applies only to those serving with or around youth and children.

If you prefer, you may refuse to answer the following question, or you may discuss your answer in confidence with the senior pastor rather than answering it on this form. Answering yes or leaving the question unanswered, will not automatically disqualify an applicant for youth or children's work.

Were you a victim of abuse or molestation while a minor? Yes No