EXHIBIT A: Application for Staff or Volunteer Service This application is to be completed by all adult leaders serving in any position involving the supervision or custody of minors or other vulnerable populations. It is being used to help (church or region) provide a safe and secure environment for those children, youth or other vulnerable populations who participate in our programs and use the facilities that (church or region) has contracted from (location of event), and to comply with the State of (state were event is being held) laws. All information disclosed will be held in strict confidence. Today's Date _________________ Personal Information Your Name _________________________________________________________________ Last First Middle Present Address ___________________________________________________________ ___________________________________________________________________________ City State Zip Home Phone #______________________ Social Security #______________________ Birth Date _______________________ 1. Have you ever been convicted of or pled guilty to any civil or criminal action including misdemeanors (example: driving under the influence, etc.)? _____ Yes _____ No (If yes, please explain__________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________) 2. Have you ever been found guilty, pled guilty or pled no contest to criminal charges or had felony criminal charges dropped because the statute of limitations had expired? _____ Yes _____ No (If yes, please explain__________________________________ ____________________________________________________________________________ ____________________________________________________________________________) 3. Have any civil lawsuits alleging actual or attempted sexual discrimination, harassment, exploitation, or misconduct; physical abuse; child abuse; or financial misconduct been successfully prosecuted against you, settled out of court, or dropped because the statute of limitations had expired? _____ Yes _____ No (If yes, please explain__________________________ ____________________________________________________________________________ ____________________________________________________________________________) 4. Have you been the subject of official proceedings involving actual or attempted sexual discrimination, harassment, exploitation, or misconduct; physical abuse; child abuse; or financial misconduct in the American Baptist Churches USA or by another denomination that resulted in any of the following? a. Growth program and/or counseling _____ Yes _____ No b. Censure _____ Yes _____ No c. Suspension of standing _____ Yes _____ No d. Termination of standing _____ Yes _____ No If yes to any of the above, please explain__________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 5. Were you a victim of abuse or molestation while a minor? _____ Yes _____ No (If you prefer, you may refuse to answer this question in writing and discuss your answer in confidence with the minister or regional executive rather than answering it on this form. Answering yes, or leaving the question unanswered, but talking to the minister or regional executive, will not, in most instances, disqualify an applicant from working with children, youth or other vulnerable populations.) 6. Do you have a current driver's license? _____ Yes _____ No (If yes, please list your driver's license information: State where issued_____and number_____________________________). Education List name and address of schools attended: Name of School and AddressNumber of Years CompletedDiploma/Degree/CertificateSubjects StudiedDates Attended Date Completed High School Vocational/Technical College/University Graduate Study/Program 2. What skills or additional training do you have that are related to working with children, youth or other vulnerable populations that can be used in this service?_________________________________________________________________ _________________________________________________________________________ Employment List names of employers in consecutive order with present or last employer listed first. Please account for all periods of time, including military service and any periods of unemployment. If self-employed, please give company name and provide business references. 1. Name of Present or Last Employer Job Title & Duties AddressDates of Employment: From: To: City, State, Zip Code Supervisor's Name Phone Number Reason for Leaving 2. Name of Present or Last Employer Job Title & Duties AddressDates of Employment: From: To: City, State, Zip Code Supervisor's Name Phone Number Reason for Leaving 3. Name of Present or Last Employer Job Title & Duties AddressDates of Employment: From: To: City, State, Zip Code Supervisor's Name Phone Number Reason for Leaving (Attach additional sheets for additional employment experiences, supplying all the information requested above.) Church History & Children, Youth or Other Vulnerable Population Ministry Experience 1. List the name of the church in which you are currently a member: Name______________________________________________ Phone #___________________ Address______________________________________________________________________ _____________________________________________________________________________ City State Zip Pastor's Name________________________________________________________________ How long have you been a member of this church?______________________________ 2. List (name and address) other churches you have attended regularly during the past five years: ______________________________________________________________________________ ______________________________________________________________________________ 3. List all previous church work and non-church work involving children, youth or other vulnerable populations (list each church/organization's name, address, type of work performed, and dates)__________________________________ _____________________________________________________________________________ _____________________________________________________________________________ 4. List any gifts, callings, training, education, or other opportunities that have prepared you for ministry with children, youth or other vulnerable populations:_________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ 5. Please provide three professional or personal references (other than family members) 1. Name________________________________________________ Phone #______________ Address______________________________________________________________________ _____________________________________________________________________________ City State Zip 2. Name________________________________________________ Phone #______________ Address______________________________________________________________________ _____________________________________________________________________________ City State Zip 3. Name________________________________________________ Phone #______________ Address______________________________________________________________________ _____________________________________________________________________________ City State Zip Applicant's 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 you any information (including opinions) that they may have regarding my character and fitness for service with children, youth or other vulnerable populations. In consideration of the receipt and evaluation of this application by [NAME OF REGION OR CHURCH], I hereby release any individual, church, youth 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. Should my application be accepted, I agree to be bound by the Bylaws and policies of [NAME OF REGION OR CHURCH]. I further state that I HAVE CAREFULLY READ THE FOREGOING RELEASE AND KNOW THE CONTENTS THEREOF AND I SIGN THIS RELEASE AS MY OWN FREE ACT. This is a legally binding agreement which I have read and understand. Applicant's Signature _______________________________________________________ Date _________________________________ Witness _____________________________________________________________________ Date _________________________________ Request for Criminal Records Check and Authorization I hereby request the _______ State Police Department and/or Federal Bureau of Investigation or private security company to release any information which pertains to any record of convictions contained in its files or in an criminal file maintained on me whether local, state, or national. I hereby release said Police Department and/or FBI or private security company from any and all liability resulting from such disclosure. ______________________________________ Signature ______________________________________ Print Name ______________________________________ Print maiden name if applicable ________________________________________________________ Print all aliases ______________________________________ Date of birth ______________________________________ Place of birth _________________________________________________________ Social Security Number ______________________________________ Today's date ______________________________________________________________________________ This section will be filled out by the church or region Record sent to: Name _________________________________________________________________________ Address ______________________________________________________________________