First Name * First Name Last Name Other/ Middle Name Date of Birth MM DD YYYY Current Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Home Phone * (###) ### #### Cell Phone * (###) ### #### Best time to call * Email Address * Emergency Contact * (###) ### #### Emergency Contact relation to you. What area of Children's Ministry would you like to volunteer? * Do you have a personal relationship with Jesus Christ? * Yes No Briefly explain how you came to embrace the gospel of Jesus Christ.W * What volunteer/ leadership experience have you had with children? * List any gifts, training, education or other facts that have prepared you to work with children. * Confidential Questions Have you ever been convicted for use or sale of drugs? * Yes No Have you ever been arrested for a criminal offense excluding minor traffic violations? * Yes No Have you ever been accused, arrested or convicted of any sexually related crimes?s * Yes No Have you ever been accused, arrested or convicted of any abuse related crimes? * Yes No Have you ever been physically, sexually, or emotionally abused? Yes No I understand that we are teaching our children to remain pure sexually until marriage, and because I understand that my lifestyle is an example to the children I will work with, I see the importance of being sexually pure myself. I affirm that this lifestyle is true to me at this time. * Yes No Are there any circumstances involving your lifestyle or your background that would call into question your ability to work with children? * Yes No References (non-family member) Name * First Name Last Name Relationship * Daytime Phone * (###) ### #### Email * Reference #2 (non-family members) Name * First Name Last Name Relationship * Daytime Phone * (###) ### #### Email * Thank you for your submission. Someone from our Children's Ministry Staff will contact you very soon.-Well-House Kids
