LAUREL STREET MENNONITE CHURCH
APPLICATION TO BECOME AN APPROVED ADULT
This application is a mandatory part of a process to assist the congregation in providing a safe, nurturing Christian environment for our children/youth. Persons responsible for the supervision and care of our children/youth are in a special position of trust and confidence. Therefore, anyone seeking to work with the children/youth of Laurel Street Mennonite Church must complete this application.
I wish to be approved as:
_______Approved Adult (requires clearance forms)
_______Helper/Teaching Assistant (works under supervision of approved adults)
PERSONAL INFORMATION
Please attach photographic identification, e.g., copy of driver’s license, school ID, etc.
(1) Name _______________________________ (2) Date of Application ________________
(3) SSN ______________________ (4) Driver’s License (State) _____________________
or other photo ID (Specify) ________________________
(5)Address__________________________________________________________________
___________________________________________________________________________
(6) Telephone (Home) _____________ (7) (Work) ____________ (8) (Cell) _____________
(9) E-mail Address ___________________________________________________________
(10) Permanent addresses you have maintained during the last five years, beginning with the most recent. ___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
(11) Are you 18 years of age or older? Yes No
Before answering questions 12 through 18 on this application, please read the Child Protection Policy of Laurel Street Mennonite Church and the page attached to this application on which appear definitions of child abuse and child sexual abuse and exploitation. In the questions below, the words “abuse,” “abusing a child” and “child abuse” are intended to include the conduct described in the definitions.
(12) Is there any reason why you should not work with children/youth? Yes No If yes, please explain. ___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
(13) Have you ever abused a child/youth (a person less than 18 years of age)? Yes No If yes, please explain. ___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
(14) Have you ever been accused of abusing a child/youth? Yes No If yes, please explain. ___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
(15) Have you ever been involved in a child abuse investigation as a witness, alleged victim, or alleged abuser? Yes No If yes, please explain. ___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
(16) Have you ever been arrested for, convicted of, or plead guilty to a criminal offense against a person?
Yes No If yes, please explain ___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
CHURCH OR CHILD-RELATED WORK (17) List your talents, training, education, etc., that might help enrich the lives of our children/youth. Describe the type of work you prefer. ___________________________________________________________________________ ___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
(18) Name and address of church (if any) of which you are now a member, if other than this congregation. ___________________________________________________________________________
___________________________________________________________________________
(19) Names and addresses of all churches you have attended on a regular basis at any time during the last five years. ___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
(20) Describe any church work you have done with children/youth during the last five years. Include th
church’s name, city, and year(s) of participation. ___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
(21) Describe any non-church related work you have done with children/youth during the last five years. Include the organization’s name, city, and year(s) of participation. ___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
PERSONAL REFERENCES
(22) Give the name, address, and phone number of two persons, not relatives, who have known you for at least five years.
(1) ________________________________________________________________________
(2) ______________________________________________________________________________
I agree that the information contained in this application is correct to the best of my knowledge.
Applicant’s Signature _____________________________________ Date_______________
APPLICATION TO BECOME AN APPROVED ADULT
This application is a mandatory part of a process to assist the congregation in providing a safe, nurturing Christian environment for our children/youth. Persons responsible for the supervision and care of our children/youth are in a special position of trust and confidence. Therefore, anyone seeking to work with the children/youth of Laurel Street Mennonite Church must complete this application.
I wish to be approved as:
_______Approved Adult (requires clearance forms)
_______Helper/Teaching Assistant (works under supervision of approved adults)
PERSONAL INFORMATION
Please attach photographic identification, e.g., copy of driver’s license, school ID, etc.
(1) Name _______________________________ (2) Date of Application ________________
(3) SSN ______________________ (4) Driver’s License (State) _____________________
or other photo ID (Specify) ________________________
(5)Address__________________________________________________________________
___________________________________________________________________________
(6) Telephone (Home) _____________ (7) (Work) ____________ (8) (Cell) _____________
(9) E-mail Address ___________________________________________________________
(10) Permanent addresses you have maintained during the last five years, beginning with the most recent. ___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
(11) Are you 18 years of age or older? Yes No
Before answering questions 12 through 18 on this application, please read the Child Protection Policy of Laurel Street Mennonite Church and the page attached to this application on which appear definitions of child abuse and child sexual abuse and exploitation. In the questions below, the words “abuse,” “abusing a child” and “child abuse” are intended to include the conduct described in the definitions.
(12) Is there any reason why you should not work with children/youth? Yes No If yes, please explain. ___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
(13) Have you ever abused a child/youth (a person less than 18 years of age)? Yes No If yes, please explain. ___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
(14) Have you ever been accused of abusing a child/youth? Yes No If yes, please explain. ___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
(15) Have you ever been involved in a child abuse investigation as a witness, alleged victim, or alleged abuser? Yes No If yes, please explain. ___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
(16) Have you ever been arrested for, convicted of, or plead guilty to a criminal offense against a person?
Yes No If yes, please explain ___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
CHURCH OR CHILD-RELATED WORK (17) List your talents, training, education, etc., that might help enrich the lives of our children/youth. Describe the type of work you prefer. ___________________________________________________________________________ ___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
(18) Name and address of church (if any) of which you are now a member, if other than this congregation. ___________________________________________________________________________
___________________________________________________________________________
(19) Names and addresses of all churches you have attended on a regular basis at any time during the last five years. ___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
(20) Describe any church work you have done with children/youth during the last five years. Include th
church’s name, city, and year(s) of participation. ___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
(21) Describe any non-church related work you have done with children/youth during the last five years. Include the organization’s name, city, and year(s) of participation. ___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
PERSONAL REFERENCES
(22) Give the name, address, and phone number of two persons, not relatives, who have known you for at least five years.
(1) ________________________________________________________________________
(2) ______________________________________________________________________________
I agree that the information contained in this application is correct to the best of my knowledge.
Applicant’s Signature _____________________________________ Date_______________
