Name *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

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Dates Served

MM

DD

YYYY

Church Phone

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1. Are there any circumstances involving your lifestyle or history that could call into question your ability to safely work with children in a Christian environment?

Yes

No

2. Have you ever been convicted or found guilty of a criminal offence for which a pardon has not been granted? (NOTE: This does not include minor traffic violations, etc.)

If yes please explain

Yes

No

3. Have you ever been expelled from or had employment terminated by any organization or employer for assault or violence?

Yes

No

4. Have you ever been investigated by the Child Welfare Agency or any other organization or government department for suspected child abuse?

Yes

No

5. Have you ever been a defendant or respondent in a civil lawsuit or human rights complaint or other legal proceeding in which you were alleged to have abused or engaged in violence, harassment, or other immoral or legal behaviour or conduct involving children, youth, or vulnerable persons.

Yes

No

6. Do you have any communicable diseases we should be aware of to help ensure we take appropriate steps to protect against transmission

Yes

No

Phone

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Phone

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Phone

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