CHILDCARE WORKER Application and Background

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Name: _________________________________

VOLUNTEER/CHILDCARE WORKER Application and Background Check

CONFIDENTIAL Fellowship Children’s Ministries VOLUNTEER/CHILDCARE WORKER APPLICATION

Office Use ONLY Application – F1 Run BC BC – F1 Send References References – F1

Personal Information Date: ___________________

Name: __________________________________________________________________________________ First Middle Last Address: ________________________________________________________________________________ Street City, State Zip Email: _________________________________________________________________________________ Home Phone: _______________________ Work: ___________________ Cell: ________________ Sex: _____ Birth date: ____/____/______ Marital Status: _________ Spouse’s Name: ____________ Do you have a personal relationship with Jesus Christ? ________________ Please briefly describe your relationship with Jesus Christ: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ How long have you attended Fellowship? ____________________ Why do you want to serve in Children’s Ministry? _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Please list any talents, training, education or other factors that may help you to work with children: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Do you have crafts experience? Yes/No

If so, what? ____________________________

Do you sing or play an instrument? Yes/No

If so, what? ____________________________

Do you lead music? Yes/No

Have drama experience? Yes/No

Story Teller? Yes/No

History of Prior Work With Children List churches or organizations other than Fellowship in which you were involved in ministry with children or youth. Church/Organization Type of Ministry Describe Your Involvement (Children or Youth) _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Do you have any MEDICAL TRAINING or are you CPR certified? _________ Explain: _________________ _____________________________________________________________________________________ _____________________________________________________________________________________

Emergency Contact Information If you have a medical condition for which you could use emergency contacts, please provide the following information: Emergency Contact: ___________________________ Relationship: _____________________________ Emergency Contact Home Phone: ______________ Emergency Contact Cell Phone: ________________ Please identify your medical condition: _____________________________________________________________________________________ _____________________________________________________________________________________ Please provide any special procedures to be followed: _____________________________________________________________________________________ _____________________________________________________________________________________ Allergies: _____________________________________________________________________________________ _____________________________________________________________________________________

Safety & Security The safety and security of children is a primary objective for us. All information is held strictly confidential by the Fellowship Children’s Ministries staff. Answering yes to any of the questions below may not necessarily preclude your involvement with the Children’s Ministry. Thank you for your understanding. Do you use illegal drugs?

Yes / No

Have you ever been hospitalized or treated for alcohol or substance abuse? Yes / No

Have you ever been accused of, arrested for, convicted of, or are you currently under investigation for a criminal offense excluding minor traffic violations? Yes / No

Have you ever been accused of, arrested for, convicted of, or are you currently under investigation for any sexually related crimes? Yes / No

Are there any circumstances involving your life-style or your background that would call into question your ability to work with children? Yes / No

Have you ever been accused of, arrested for, convicted of, or are you currently under investigation for any abuse related crimes? Yes / No

If you answered yes to any of the above questions please explain: _______________________________ _____________________________________________________________________________________ _____________________________________________________________________________________

Reference Request Form List two personal references (not former employers or relatives). Please give complete mailing addresses and telephone numbers. First & Last Name

Street Address

City, State

Zip

Area Code & Telephone

________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________

Release Statement

The information contained in this application is correct to the best of my knowledge. I authorize any references or churches listed in this application to give you any information (including opinions) that they may have regarding my character and fitness for working with children or youth. I release all such references from liability for any damage that may result from furnishing such evaluations to you and I understand that any omission of material fact on this application may be grounds for rejection of this application. I waive any right that I may have to inspect any information provided about me by any person or organization identified by me in this application.

Applicant’s Signature: _______________________________________________ Date: ________________

Background Screening Consent Applicant should complete all relevant information and sign and date the form. I, ______________________________________, hereby authorize Fellowship Bible Church and/or its agents to make an independent investigation of my background, references, character, past employment, education, credit history, adult criminal or police records, and motor vehicle records including those maintained by both public and private organizations and all public records for the purpose of confirming the information contained on my Application and/or obtaining other information which may be material to my qualifications for service now and, if applicable, during the tenure of my employment or service with Fellowship Bible Church. I release Fellowship Bible Church and its agents and any person or entity, which provides information pursuant to this authorization, from any and all liabilities, claims or law suits in regards to the information obtained from any and all of the above referenced sources used. The following is my true and complete legal name and all information is true and correct to the best of my knowledge: Full Name (Printed): _____________________________________________________________ Maiden Name or Other Names Used: _______________________________________________ Social Security Number: _________________________ Date of Birth*: _____/_____/19______ Present Address: ________________________________________________________________ City: ______________________________________ State: __________ Zip: ________________ How Long at Present Address? _____________________________________________________ Former Address: ________________________________________________________________ City: ______________________________________ State: __________ Zip: ________________ How Long at Former Address? _____________________________________________________ Please list all states and counties of residence since turning age 18: ______________________________________________________________________________ ______________________________________________________________________________ (Please circle any of the following states in which you have lived: CA, CO, DE, LA, MA, SD, VT, WV, WY)

Driver's License Number: ___________________________ State of License: _______________ _____________________________________________________________________________ Signature of Applicant / Date Are you applying for employment in California, Minnesota or Oklahoma? Yes: _____ No: _____ If so, do you want a copy of any Consumer Report prepared concerning you? Yes: ___ No: ____ I understand that California law requires Fellowship Bible Church to give me a copy of any report requested within seven (7) days of the date the information was obtained and that failure to do so will expose Fellowship Bible Church to liability (Section 1786.29). *NOTE: The above information is required for identification purposes only, and is in no manner used as qualifications for employment, internship, or service as a volunteer. Fellowship Bible Church abides by all applicable state and federal employment laws.

PHOTO RELEASE FORM

I hereby consent to and authorize the use and reproduction, in print or electronic format, by Fellowship Bible Church or anyone authorized by Fellowship, of any and all of my photos and/or footage for any publicity purpose, without compensation. All images—electronic, negatives and positives, together with the prints, are owned by Fellowship. I also give unrestricted permission to use, display, distribute, publish, and copy, either digitally or by means of print whether by Internet, CD, magazine, brochure, newspaper, TV or other types of media without restrictions. I also understand that my name may or may not be used with the photographs taken of me or the photographs that I may be included in. I release the photographer and any agents associated with the photographer of any claims, demands, lawsuits, that may arise in connection with the photographs taken. In the event I no longer desire for my image/photos to be used by Fellowship, I agree to notify Fellowship in writing. I am over 18 years of age. I understand the above release agreement and that this agreement is binding upon my signature. If not 18 years of age, release form must be signed by legal parent/guardian.

Date: _______________________________________________________________ Signature: ___________________________________________________ Print Name: _________________________________________________ Parent/Guardian: ____________________________________________ Address: __________________________________________________ City/State/Zip: _______________________________________________ Phone: ____________________________________________________ Email: ____________________________________________________ FELLOWSHIP BIBLE CHURCH Communications Department 1210 Franklin Road Brentwood, TN 37027 (615) 777-8500 / www.FellowshipNashville.org