Statement of Privacy
This authorization form is to be completed by all applicants over the age of 18 for any position involving the supervision or custody of minors. This is not an employment application form. This form is being used to help our church provide a safe and secure environment for those children and youth who participate in our programs and use our facilities. The completed form will be available only to designated Holy Cross staff members. Once the approval process has been completed, this document will be maintained in a secure file location.
Home Phone:
Maiden/and or Previous:
Home Address:
Date of Birth:
Are you a member of Holy Cross Lutheran Church:
If yes, how long?:
If no, what is the name and city of the church you have been attending?
Personal References needed if applicant has been a member less than 3 years. Please list two people other than relatives.
Reference #1 Name:
Phone (#1):
Relationship (#1):
Address (#1):
Reference #2 Name:
Phone (#2):
Relationship (#2):
Address (#2):
Have you ever been convicted of, pleaded guilty to or no contest to a felony or misdemeanor involving assault, domestic violence, child abuse/neglect?
If yes, please explain:
Have you ever been convicted of physical or sexual abuse of a minor?
If yes please explain:
Applicant’s 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 Holy Cross Lutheran Church any information that they may have regarding my character and fitness for working with children or youth. I authorize that a criminal records check be conducted on me once a year as long as I am volunteering in any position involving children and/or youth or as long as I remain on staff. I agree to hold harmless from liability any person or organization that provides or receives information. I also understand that I am required to attend a Child Protection Training Workshop. I agree to abide by the guidelines and policies of Holy Cross Lutheran Church. _____________________________________________________________________________________________________________ Signature (by typing your name here you are electronically signing your name):