Volunteer Safety Application

Safety Application Form for Volunteers and Employees
Confidential

This application should be completed by all applicants for any position (volunteer or employment) involving the supervision of children or students. This is not an employment application. The purpose of this form is to assist in the creation of a safe environment for children or students who participate in the programs of West Acres Baptist Church or use West Acres facilities. If prefer to complete a hard copy of this application please contact the church office.

* Indicates required field

Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Email *

Phone Number *

Sex *

Male Female

Date of Birth *

Marital Status *

Please list all previous volunteer work or employment involving children or students (List each organization's name and address, type of work, dates, and a contact person familiar with your work there.) *

List any talents, vocations, preparation, training or other experiences that have equipped you to work with children or students *

REFERENCE FORM FOR PROSPECTIVE VOLUNTEERS/EMPLOYEES

References Required: Each applicant must submit the names and phone numbers of at least one professional reference, one personal reference and one family member. Additional professional references may be submitted if deemed helpful by applicant in allowing West Acres Baptist Church to determine applicant’s fitness for volunteer position and qualifications. The professional references should be familiar with the quality of the individual’s work. One of these references should be a person of the opposite sex.

Personal Reference: Please list the name, email, address, city & state, zip code, and phone number *

Professional Reference: Please list the name, email, address, city & state, zip code, and phone number *

Family Reference: Please list the name, email, address, city & state, zip code, and phone number *

Because we care for children and desire to protect them, please answer the following questions. We understand that the answers to these questions may be private and deeply personal, and we will protect your privacy in every possible context. It is the position of West Acres that suspicions or allegations of child abuse or neglect will be reported to relevant state authorities.

Why do you want to work with children or students at West Acres? *

Do you have a preference concerning the age group or sex of children or students with whom you would like to work? If so, what is the basis for this preference? *

What is your philosophy concerning re-direction or discipline of children? *

When you are unhappy, angry or emotional about a person or circumstance, what do you do? *

Has someone ever accused you of physically or sexually abusing a child, or molesting a child? *

Do you consider yourself to have been physically or sexually abused as a child? *

Yes No

(We realize this information is potentially sensitive, and it will be kept entirely confidential, where another child’s safety is not negatively impacted by confidentiality.) If so please explain: *

If you answered ‘yes’ to this question, would you consider counseling or resources (available through the West Acres) to address any resulting emotional or spiritual harm or damage? *

RELEASE

I authorize West Acres to contact all individuals, organizations and references listed on this Safety Application Form in order to verify the information I have provided. I agree to release from liability any person or organization providing information related to me, including those persons I have listed as references, as well as contact persons from my previous volunteer work or employment with children.

I specifically authorize West Acres to undertake a criminal background check concerning my past.

I understand and agree that any information received from the background check and application verification will not be disclosed to me except as required by law, and I hereby waive any right I may have to inspect any information provided about me by any person or organization identified by me on this form.

By typing my name and checking this box, I certify and affirm that the information I have given on this form is true, complete and correct in all respects.

Name *

First

Last

Check this Box *

I certify and affirm the information I have given is true

Submit

Safety Application Form for Volunteers and EmployeesConfidential

REFERENCE FORM FOR PROSPECTIVE VOLUNTEERS/EMPLOYEES

RELEASE

Safety Application Form for Volunteers and Employees
Confidential