Employee and Volunteer Ministry Application Form

Full Name *

First

Middle

Last

Email *

Address *

Address Line 1

City

State

Zip Code

How many years at this address? *

Home and/or Cell Phone *

Work Phone

Occupation and Name of Employer

Starmount Presbyterian Church member since

List other churches attended regularly during the last five years.(names and address) *

What leadership/volunter experience have you had with children/youth? (Be specific, where possible include dates and places other than Starmount Presbyterian Church) *

Please list any other Starmount Presbyterian Church ministries that you are involved in. *

NOTE: CONFIDENTIAL INFORMATION - TO BE USED ONLY AS STATED IN POLICY

Birth Date *

Drivers License Number and State of Issuance *

Traffic Violations *

Have you ever been convicted of or pled guilty or no contest to traffic violation(s) in the last five years? If yes, describe dispostion of case below

above organization? traffic

Medical Training/CPR Certified? *

Health Related Issues *

Is there any health related reason that would keep you from effectively working with or cause any potential harm to children? If yes, please explain below

Explanation for "Yes" answers noted above

Personal References - include name, phone number and relationship (3 required) *

Please note:

The questions listed below are necessary in order to help ensure a safe and secure environment for our children and for the protection of our volunteer and/or paid staff. All information is held strictly confidential. If you have any concerns regarding the questions, please consult with the Associate Pastor.

Have you been convicted for the use or sale of drugs? *

If Yes, explain below

Have you been hospitalized or treated for alcohol or substance abuse? *

If Yes, explain below

Have you been convicted of a criminal offense excluding minor traffic violations? *

If Yes, explain below

Have you been arrested or convicted for any sexually related crimes? *

If Yes, explain below

Have you ever been denied participation in supervising youth activities in any organization? *

If Yes, explain below

Explanation for "yes" answers noted above

Select Church or Preschool as the primary location in which you will be working with children at Starmount *

CALLED TO WORSHIP, EMPOWERED TO SERVE.

CALLED TO WORSHIP, EMPOWERED TO SERVE.

Employee and Volunteer Ministry Application Form

NOTE: CONFIDENTIAL INFORMATION - TO BE USED ONLY AS STATED IN POLICY

Please note: