Volunteer Application for Youth Ministry Team
Contact Information
NameStreet Address
City ST ZIP Code
Home Phone
Work Phone
E-Mail Address
Special Skills or Qualifications
Summarize special skills and qualifications you have acquired from employment, previous volunteer work, or through other activities, including hobbies or sports.Previous Volunteer Experience
Summarize your previous volunteer experience.Agreement and Signature
By submitting this application, I affirm that the facts set forth in it are true and complete. I understand that if I am accepted as a volunteer, any false statements, omissions, or other misrepresentations made by me on this application may result in my immediate dismissal.Name (printed)
Signature
Date
Thank you for completing this application form and for your interest in volunteering with us.
Please mail this to the Youth Coordinator – PO BOX 721 Three Forks, MT 59752
Yellowstone Applicant Background Check Disclosure Affidavit
(Revised May 18, 2011)
The Yellowstone Conference screens prospective employees and volunteers to ensure the safety and well-being of participants, guests and staff—particularly children, youth, vulnerable adults and developmentally challenged persons. Joining with many parents, legislative bodies and children/youth organizations, we require disclosures by all persons who will be working in conference ministry settings including but not limited to: local churches, camping, UMVIM, youth events, and retreats.
All volunteers or hired persons who will participate in overnight or multi-day settings must fill out this form completely and return it at least two weeks prior to you beginning service. Information obtained does not automatically disqualify an applicant, but is considered on a case-by-case basis in view of all relevant circumstances. Completion of this affidavit and a background check is required by applicants in order to participate in Yellowstone Conference ministry areas. Please read and complete the requested information carefully, as any falsification, misrepresentation, or incompleteness in this disclosure is grounds for disqualification.
Name (Last, First, Middle)
Any Former Names (Last, First, Middle) & Date Used (e.g. Smith, Junior, B. 1987-2001)
Current Address Since_____(street, city, state, zip code)
Date of birth (Month/Day/Year)Social Security Number
Phone number(s)Drivers License Number/State
List any City & State or City & Country or Territory where you have lived for the past 10 years, along with the year(s) you lived there (for example: 2005-present Helena, MT).
Have you ever been convicted of; pleaded guilty to (whether or not resulting in a conviction); pleaded nolo contendere or no contest to; admitted; had any judgment or order rendered against me (whether by default or otherwise); entered into any settlement of an action or claim of; had any license, certificate or employment suspended, revoked, terminated, or adversely affected because of; been diagnosed as having or been treated for any mental or emotional condition arising from; or resigned under threat of termination of employment or volunteer work for; any allegation, any conduct matter, or thing (irrespective of the formal name thereof) constitution or involving (whether under criminal or civil law of any jurisdiction)**:
YesNo(Initial under “Yes” or “No” for each item.)
______Any felony.
______Rape or other sexual assault.
______Drug or alcohol related offenses.
______Abuse of a minor or child, whether physical or sexual.
______Incest.
______Kidnapping, false imprisonment, or abduction.
______Partner/Family Member Assault.
______Sexual harassment.
______Sexual exploitation of a minor.
______Sexual conduct with a minor.
______Criminally annoying/molesting a child.
______Lewdness and/or indecent exposure.
______Lewd and lascivious behavior.
______Obscene literature.
______Assault, battery or other offense involving a minor.
______Endangerment of a child.
______Violation of a protection, restraining, or no-contact order.
______Any misdemeanor or other offense classification involving a minor or to
which a minor was a witness.
______Unfitness as a parent or custodian.
______Removing children from a State or concealing children in violation of a law
or court order.
______Restrictions or limitations on contact or visitation with children or minors.
______Similar or related conduct, matters, or things.
______Accusation of any of the above.
If you answered “Yes” to any of the above, please describe the circumstances including the dates. If none, write “None”.
The above statements are true and complete to the best of my knowledge.
______
DateApplicant’s signature
______
DateWitness to signature
**The source for this form is “Guidelines for the Screening of Persons Working with Children, the Elderly, and Individuals With Disabilities in Need of Support” (U.S. Department of Justice, Office of Juvenile Justice and Delinquency Prevention).
Thank you for completing this application form and for your interest in volunteering with us.