Child Protection Initial Screening Form – Pfrimmer's Chapel Forms

Presentation Option(Required)

I have watched the above video presentation highlighting the Child Protection Guidelines in its entirety from start to finish.

I have attended an in person presentation highlighting the Child Protection Guidelines in its entirety from start to finish.

Date and Location of In Person Presentation(Required)

Name(Required)

First Middle Last

Any Previous Name(s)

Current Address(Required)

Street Address Address Line 2 City State ZIP Code

Current County of Residence(Required)

How long have you lived at this address?(Required)

Previous Address

Street Address Address Line 2 City State ZIP Code

Primary Phone(Required)

Work Phone

Date of Birth(Required)

Have you ever been convicted of a misdemeanor or felony crime?(Required)

Yes

No

If yes, please explain.(Required)

Have you ever been accused, charged, or alleged to have, or have you ever committed any act of neglecting, abusing, or molesting any child?(Required)

Yes

No

If yes, please explain.(Required)

Are there any circumstances or patterns in your life which would make it inappropriate for you to serve with minors or would compromise the integrity of Pfrimmer's Chapel?(Required)

Yes

No

If yes, please explain.(Required)

Have you ever been treated for a psychiatric disorder?(Required)

Yes

No

If yes, please explain.(Required)

Church History & Prior Work with Children/Youth

Home Church(Required)

This is the church where you are a member or attend regularly.

Which ministries would you like to serve?(Required)

Nursery

Camp Freedom

VBS

Children’s Church

Youth Ministry

Other

Other(Required)

Name(s)/Address(es) of the Church(es) You Attended Over the Past Five Years(Required)

Church Name

Church Address

Dates Attended

Church Work Involving Children/Youth

Please describe any church work you did involving children/youth at the above listed churches.

Non-Church Work Involving Children/Youth

Please describe any church work you did involving children/youth.

Gifts, Callings, Training, Education, and More

Please describe your gifts, callings, training, education, and other factors that have prepared you for work with children/youth.

References

Please list three (3) personal references that you have known for at least one year and have a definite knowledge of your character and ability to work with children: one must be a relative that does not live with you and one other must be from outside our church.

Reference 1 Name (Relative)(Required)

First Last

Relationship of Reference 1 (Relative)(Required)

Reference 1 Phone Number(Required)

Reference 2 Name(Required)

First Last

Relationship of Reference 2(Required)

Reference 2 Phone Number(Required)

Reference 3 Name(Required)

First Last

Relationship of Reference 3(Required)

Reference 3 Phone Number(Required)

Applicant Statement & Release

Consent(Required)

I affirm that the below statement is true.

The information contained in this application is true and correct to the best of my knowledge. I authorize any references or churches listed in this application to give you any information they may have regarding my character and fitness for work with children/youth. I also authorize the church to submit my name and social security number for a National/State/County Criminal Background Screening. Should my application be accepted, I agree to be bound by the Child Protection Guidelines and Procedures of Pfrimmer’s Chapel United Methodist Church.

I further state that I HAVE CAREFULLY READ THE FOREGOING RELEASE AND KNOW THE CONTENTS THEREOF AND I AGREE TO THIS RELEASE AS MY OWN FREE ACT. This is a legally binding agreement which I have read and understand.

Signature

I am a minor (under the age of 18 years old).(Required)

Yes

No

Parent Name

First Last

Consent(Required)

I affirm that the below statement is true.

To my knowledge, the applicant has not engaged in any illegal activity or child abuse of any kind and I know of no reason why he or she should not work with children/youth at Pfrimmer’s Chapel United Methodist Church.

Parent Signature(Required)