Child Worker Application
Date:
Last Name:
First Name:
Middle Name:
Current Address:
City: State: Zip Code:
Home Phone: Work Phone:
Alternate Phone:
Email Address: (If you do not have email please mark N/A in the box.)
Date of Birth: Place of Birth:
Social Security Number:
Drivers License Number
Please List any Previous Address in the Past 5 Years if Applicaple:
What days are you available: Sunday Monday Tuesday Wednesday Thursday Friday Saturday
Have you ever been charged with, convicted of, or plead guilty to, child abuse or a crime involving any actual or attempted harm of a minor?
Yes No If Yes, Please explanin:
Have you ever been charged with, convicted of, or plead guilty to, an offense other than a minor traffic vilolation? Yes No
If Yes, Please explain:
Please list your three most recent employments and reason for leaving, if none place NA in the Boxes.
Employment # 1
Employment # 2
Employment # 3
Please list your previous expeirence with Children. (i.e. ages, responsibilities, etc.)
Have you had any special training for the position you are applying for?
What is the name of the church in which you are currently a member?
Please list the names and addresses of all other churches you have attended on a regular basis during the past five years.
Please list Two Personal References: (not including family or former employers)
Reference # 1
Reference # 2
Applicants Statement:
The information contained in this application is correct to the best of my knowledge. I do hereby authorize any reference or church listed in this application to give you any information, including opinions, that they have regarding my character and/or suitability for working with children. I also release all such references from any liability for furnishing such evaluations to you, provided they do so in good faith and without malice. I also waive my right to inspect any reference provided on my behalf.
In addition, I hereby give consent to Harvest Time Assembly of God or its authorized agents to secure background checks, whether criminal or driving, or other, which they deem necessary to truthfully evaluate my suitability for working with children. I understand that any information given by me or obtained by Harvest Time Assembly of God will be held in the strictest confidence.
Should my application be accepted, I agree to adhere to the policies and procedures, as well as bylaws of Harvest Time Assembly of God.
Please type your full name as a form of signature and agreement with this statement: