Volunteer and Staff Background Authorization Form

Statement of Privacy

This authorization form is to be completed by all applicants and/or volunteers 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. All Potential staff and volunteers are required to read the Youth and Child Protection Policy.

Date

Cell Phone

Alt Phone

Last Name

First Name and Middle Initial

Maiden and/or Previous Name

Street Address

City

Zip Code

Email Address

Date of Birth (required for background check)

Race

Are you a member of Holy Cross Lutheran Church?

If yes, how long?

If you are not a member of Holy Cross Lutheran Church, please indicate the church you have been attending and its location.

Personal references needed if applicant has been a member of Holy Cross Lutheran Church for LESS THAN 3 YEARS. Please list two people other than relatives.

1. Reference Name

Phone

Relationship

Address

2. Reference Name

Phone

Relationship

Address

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. If no, type N/A

Have you ever been convicted of physicall or sexual abuse of a minor?

If yes, please explain. If no, type N/A.

Youth and Child Protection Policy

I acknowledge I have read and will abide by the Child Protection Policy.

Applicant's Statement and Signature

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 received 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.

I agree that typing my full name in the box below is same as a handwritten signature and carries the same force for purposes of validity, enforceablility, and admissibility.

Date

If you are having difficulty completing the online form, you may download the form HERE and return it to the Holy Cross Office M-F from 9-5.

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Volunteer and Staff Background Authorization Form

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