EmailMe Form - DISCLOSURE STATEMENT

The information on this form is confidential with the goals of protecting our children and shepherding an applicant as appropriate. This application will be seen by one designated elder appointed by the session. In some instances, this elder may share information with the session if the elder believes a child may be at risk.

Note: Answering ‘yes’ to any of the questions below does not necessarily disqualify you as a candidate but will provide an opportunity for shepherding if necessary.

Name *

First Middle Last

Date of Birth *

MM / DD / YYYY

Age *

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code

Email

Necessary for a response email.

1a. Have you ever been convicted of a crime against another person or are you the subject of pending charges of any crime against another person? *

Yes

No

1b. If yes or pending, please explain.

2a. Have you ever been accused of sexual abuse towards someone under 18 years old?

Sexual abuse is defined as any contact or interaction (visual, verbal, or psychological) between a child/adolescent and an adult when the child/adolescent is being used for the sexual arousal, molestation, or gratification of the perpetrator or any other person (Allender, The Wounded Heart, Navpress, 1993). *

Yes

No

2b. If yes or pending, please explain.

3a. Have you ever been accused of or been the subject of a founded complaint of child abuse or neglect? *

Yes

No

3b. If yes or pending, please explain.

4a. Do you currently or have you ever intentionally looked at child pornography? *

Yes

No

4b. If yes or pending, please explain.

5a. Do you struggle with knowing appropriate physical or emotional boundaries with children? *

Yes

No

5b. If yes or pending, please explain.

Affirmation of Information *

I hereby affirm that the information provided on this form is true and complete. I understand that the information is subject to verification.

Signature
If under the age of 18, please have a parent sign on the line to the right.

Clear