C3 Kids Application
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PERSONAL INFORMATION
A description of the section goes here.
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| Name:
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| Prefix
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| First
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| Last
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| Address:
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| Street Address
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| Address Line 2
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| City
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| State / Province / Region
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| Postal / Zip Code
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| Country
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| Contact:
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| Phone Number
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| Email
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| Have you ever been arrested for any reason?
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Yes No
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| Been convicted of, or pleaded no contest to, any crime?
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Yes No
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| Engaged in, or been accused of, any child molestation, exploitation, or abuse?
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Yes No
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| If the answer to any of the questions above is yes, please explain in detail...
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| What other childrens work experience do you have?
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AREA(S) OF INTEREST
A description of the section goes here.
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| Please indicate what type of children's work you prefer...
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infants 2,3,4 yr olds K, 1st, 2nd grade 3rd-6th grade
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| Which service do you prefer to work?
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9:15am 11:15am
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| Please indicate the date you would be available to begin?
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| What is the minimum length of commitment you can make?(we ask for 3 months initially)
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| What qualities do you have that would help you work with children?
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PERSONAL REFERENCES
other than relatives
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Reference #1
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| relationship to reference?
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Reference #2
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| relationship to reference?
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| Name
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| Phone Number
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APPLICATION STATEMENT
The information contained in this application is correct to the best of my knowledge. I authorize any references or churches listed in this application to give any information (including opinions) that they may have regarding my character for work with children. In consideration of this evaluation by C3 Church of Pickerington, I herby release any individual, church, organization, charity, employer, reference, or any other person or organization including record custodians, both collectively and individually, from any and all liability for damages of whatever kind or nature which may at any time result to me, my heirs, or family, on account of compliance or any attempts to comply, with this authorization. I waive any right that I may have to inspect any information provided about me by any person or organization identified by me in this application.
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| Name
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| Date
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REQUEST FOR CRIMINAL RECORDS CHECK AND AUTHORIZATION
During this application process and at any time during the tenure of my volunteer status with C3 Church in Pickerington, Ohio, I hereby authorize LexisNexis., on behalf of C3 Church, to procure a national background check. This report may be compiled with information from court records, repositories, departments of motor vehicles, past or present employers, and educational institutions, governmental occupational licensing or registration entities, business or personal references, and any other source required to verify information that I have voluntarily supplied. I understand that I may request a complete and accurate disclosure of the nature and scope of the background verification.
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| Name
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| First
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| Date
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| SSN:
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| Date of Birth
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| Aliases (if applicaple)"
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| Maiden Name (if applicaple)"
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Image Verification
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