Children’s Ministry Application This application should be completed by all applicants for any position (volunteer or employment) involving the supervision of minor children. Step 1 of 6 16% General InformationName* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Middle Last Suffix Have you been known by any other names?* Yes No Please list other names you've been known by Date of Birth* Social Security Number* This website and form are encrypted, your information will be kept secure.Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Have you lived in Pennsylvania for the last 10 years in a row with NO breaks?*YesNoPhone*Email* Are you a member of Grace City Church of the Northeast?* Yes No How many years have you attended Grace City Church?* In which children’s or student ministry(ies) do you want to become involved?* Infant Nursery Toddler Nursery 3-5 class 6-9 class Children's Choir VBS Youth Group Select all that apply Prior Church InformationPlease list the name, address, city, and state of any other churches you have attended regularly during the past 10 years. If Grace City has been your only church please enter n/a.Please list each church on a separate line*If you previously volunteered at another church over the last 10 years, please list the type of work, a contact person, & a contact phone number. Other ExperiencesPlease list all previous non-church work involving children or students.Please include: Organization Name, Address, City, Type of work, Dates, Contact Person, and a Contact Phone for each place of experience.List any talents, vocations, preparation, training or other experiences which have equipped you to work with children or students. Personal & Confidential QuestionsBecause our church cares for our members and our children, and desires to protect them, please answer the following questions. We understand that the answers to these questions may be private and deeply personal, and we will protect your privacy.Why do you want to work with children or students at Grace City Church?*Do you have a preference concerning the age group or sex of children or students with whom you would like to work? Why?*What is your philosophy concerning re-direction or discipline of children?*When you are unhappy, angry, or emotional about a person or circumstance, what do you do?*Have you experienced any significant physical or emotional stresses within the past year, such as the loss of a parent, spouse, or child, extreme ill health, or any emotional or physical crisis?*YesNoIf Yes, Please ExplainDo you consider yourself to have been physically or sexually abused as a child? (This information will be kept entirely confidential.)*YesNoIf you were physically or sexually abused as a child, would you consider utilizing church resources to seek healing in this area of your life?*YesNoHave you ever physically or sexually abused a child?*YesNoIf Yes, Please ExplainHas someone ever accused you of abusing a child?*YesNoIf Yes, Please ExplainHave you ever been arrested for any reason?*YesNoIf Yes, Please ExplainHave you ever been convicted of or pleaded guilty or no contest to any crime?*YesNoIf Yes, Please ExplainDo you have any concerns about working in this area of ministry?*YesNoIf Yes, Please ExplainAre you aware of having any traits or tendencies that could pose any threat to children, students, or others?*YesNoIf Yes, Please ExplainAre you aware of any reason that you should not work with children, students, or others?*YesNoIf Yes, Please Explain ReferencesPlease list at least two references below. References must include one non-family member and one member of the opposite sex. Please contact these references and inform them an authorized Grace City Church of the NE staff person will be contacting them.Reference #1* First Last Address - Reference 1* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone - Reference 1*Reference #2* First Last Address - Reference 2* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone - Reference 2* Background Check Authorization and ReleaseI authorize Grace City Church to contact any person or entity listed on this application, and I further authorize any such person or entity to provide the organization with information, opinions, and impressions relating to my background or qualifications. I understand that, in accordance with the laws of the Commonwealth of Pennsylvania, a consumer report (background screening report) and/or an investigative consumer report (reference checks and/or interviews) that may include information from public or private sources regarding my character, driving records, criminal history, court records (both civil and criminal), qualifications and experience, work habits, and/or other information relevant to my volunteer service will be obtained in connection with my application as a volunteer with Grace Bible Church. I understand that, if I am approved for volunteer service by Grace City Church, this background check authorization will be kept on file and may be used at any time during my service to procure further information when, in the judgment of Grace City Church, such may be necessary. I hereby release and discharge to the extent permitted by law, Grace City Church, its employees, any individual or agency obtaining information for Grace City Church, any entity listed on this application, and any personal or professional reference, from any and all claims, damages, losses, liabilities, costs, or other expenses arising from the retrieving, reporting and/or disclosure of information in connection with this background investigation. I understand that I am volunteering my services and declare in no way shall I be considered an employee or subcontractor or independent contractor of Grace City Church based on this application. I understand that this is not an employment application. I understand and agree that any information received from the background check and application verification will not be disclosed to me, and I hereby waive any right I may have to inspect any information provided about me by any person or organization identified by me on this form. I have read, understand, and consent to the above. I further authorize that a photographic copy or a telephonic facsimile of this document shall be valid for purposes present and future. My electronic signature below certifies that all information I have provided in connection with this background check is true, accurate and complete to the best of my knowledge.Signature* Please Type Your Complete Name Δ
