Pfrimmer's Chapel Forms

Child Protection Initial Screening Form

This form is to be completed by anyone supervising or assisting with children/youth. It is not an employment application form. This form is used to help our church provide a safe and secure environment for the children and youth who participate in our ministries and programs. A background check will be performed on all applicants.

Step 1 of 5

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Presentation Option(Required)
Name(Required)
Current Address(Required)
Previous Address
MM slash DD slash YYYY
Have you ever been convicted of a misdemeanor or felony crime?(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)
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)
Have you ever been treated for a psychiatric disorder?(Required)

Church History & Prior Work with Children/Youth

This is the church where you are a member or attend regularly.
Which ministries would you like to serve?(Required)
Name(s)/Address(es) of the Church(es) You Attended Over the Past Five Years(Required)
Church Name
Church Address
Dates Attended
 
Please describe any church work you did involving children/youth at the above listed churches.
Please describe any church work you did involving children/youth.
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)
Reference 2 Name(Required)
Reference 3 Name(Required)

Applicant Statement & Release

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