Cary Alliance Church

Cary Alliance Church

Background Investigation Information Form

Youth and Children’s Ministry Staff and Volunteer Applicants

Disclosure Statement

This application is to be completed by all applicants for CAC Youth and Children’s Ministry positions. This form is being used to help the church provide a safe and secure environment for the youth and children entrusted to our care. Information on this form is considered secure and confidential and will be shared, only if necessary, with the elders of Cary Alliance Church.

Authorization Statement

During the application process and at any time during the tenure of my employment/volunteer service with Cary Alliance Church, I hereby authorize Protect My Ministry on behalf of Cary Alliance Church to procure a Background Investigation report. This report will include social security number verification, and national, state, and local checks for criminal files or sexual/violent offender records. I understand that I may request a complete and accurate disclosure of the nature and scope of the background verification to the extent that such investigation includes information bearing on my character, general reputation, personal characteristics or mode of living.

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Applicant/Employee Signature Date

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Social Security Number Date of Birth (Month / Day / Year) (for identification only)

Personal Information

Full Name ______

Last First Middle Nickname

Former Names (if any) ______

Current Address ______
House/Apt # Street Name City State Zip Code

Telephone: (Home)______(Mobile)______(Work)______

Email ______

Additional Addresses

Please provide any additional addresses AND THE COUNTY you have lived in during the past seven years. Use the bottom of page 4 if necessary.

Address ______
House/Apt # Street Name City State Zip Code County

How long have you been regularly attending (= 2 or more services/month) Cary Alliance? ______

Are you a member of Cary Alliance Church? ____Yes ____No

If “no”, are you willing to attend our membership class? ____Yes ____ No

Please indicate the age(s) that you would prefer to serve in order of preference:

____ Infants ____ 4 year olds ____ Junior High 6th-8th grade

____ 1 year olds ____ 5yr-K ____ High School 9th-12th grade

____ 2 year olds ____ 1st-2nd grade

____ 3 year olds ____ 3rd-5th grade

Please indicate the day(s) and ministries you desire to serve in:

____ Sunday (9:15am Nursery) ____ Sunday (10:30am Nursery)

____ Sunday (9:15am Sunday School) ____ Sunday (10:30am Junior Church)

____ Sunday (5:15pm T&T Awana) ____ Sunday (10:30am Children’s Church)

____ Sunday (7:00pm Youth Group) ____ Sunday (5:45pm Awana)

____ Wednesday/Saturday (Childcare for Choir) ____ Wednesday (7:00pm children’s choir)

____ Wednesday (7:00pm Youth Group) ____ Substitute Teacher/Assistant

____ Tuesday (9:15 Women’s Bible Study) ____ Wednesday (9:15am MOPS)

____ Vacation Bible School (Summer Only) ____ Kids Camps (Summer Only)

Required Background Questions

1. Have you ever been convicted of or pleaded guilty to a crime involving abuse or inappropriate conduct to or involving a minor? ____ No ____Yes If "yes", please explain below

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2. Are you currently under any investigation or pending charge? ____No ____ Yes If yes, explain______

3. Have you ever been subjected to expulsion, reprimand, or other discipline by a church, denomination or other religious organization? ____Yes ____No If yes, please explain______
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4. Do you have any contagious or infectious disease or condition which could be transmitted to other volunteers or children? ____Yes ____No If yes, please explain.______

Note: If you have answered affirmatively to any of the above questions in this section, it will be necessary for you to meet with one of the pastors concerning your response. Your meeting with the pastor will be kept in the strictest confidence. Please also note that all applicants working with minors at Cary Alliance Church may be subject to police background checks if deemed necessary.

5. Please describe any condition which might restrict or prevent you from performing certain activities involved in the position for which you are being considered (e.g. lifting toddlers, handling an emergency, driving, participating in certain sports). ______
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Church History and Prior Youth/Children’s Ministry

1. Please list (name, address, and phone) of other churches you have attended regularly during the past 7 years:

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2. List all previous church work involving children and/or youth. Please list each church name, type of work performed, and dates served.

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3. List any gifts, callings, training, education, or other factors that have prepared you for serving.

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4. Briefly state how you came to know Jesus as your personal Lord and Savior.

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Personal References: (Provide 2 non-family personal references who know you well)

Name: ______Name: ______

Address: ______Address: ______

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Telephone: ______Telephone: ______

Email: ______Email: ______

Applicant Statement

All the information I have provided on this document is accurate to the best of my knowledge.
I authorize Cary Alliance Church to contact the references I have provided. Additionally, I have talked with a pastor of Cary Alliance Church concerning any positive responses to questions #1-4 under the section “Required Background Questions”.

I have carefully and completely read current policies regarding youth and/or children’s ministries at Cary Alliance Church and understand the content of these policies. I will strictly comply with all policies and procedures of the Cary Alliance Church. If at any time I find that for any reason I am unable to support the policies and procedures of this church, I will resign my position. I understand and agree that failure by me to abide by such policies and procedures may result in my removal from my position of service. I understand that my services to the church may be terminated at any time if deemed necessary by the pastor overseeing the particular area of ministry and the Board of Elders.

This statement will remain in effect for the duration of my service at Cary Alliance Church.

Signature ______Date______

Parent/Guardian Signature ______Date______

(only required if applicant is under 18 years old)

(Please use the space below as a continuation for any question or to provide any additional information you think we should know about. Thank you for your willingness to serve the Lord Jesus and His people through this ministry!)

CAC Background Check (Oct 2008) - Page 1 of 4