RE:KIDS VOLUNTEER APPLICATION

Name *

First Name

Last Name

D.O.B *

MM

DD

YYYY

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Have you gone through RE:VEAL? *

Yes

Not Yet

What age group do you prefer working with? *

Note: we try to accommodate as best as possible.

0-3 yrs

4-6 yrs

7 & up

No Preference

1. Have you been convicted of an offense other than a minor traffic violation(s)? *

YES

NO

2. Have you ever been convicted of a sexual offense, offense relating to children, abuse, Yes No or crime of violence (that is not covered in question 1)? *

YES

NO

3. Have you ever been sexually abused, or been the victim of abuse in any form? If so, describe any counseling you have received for that. *

YES

NO

4. Have you ever been the subject of any disciplinary action, transfer or dismissal, as a result
of an accident or mishap involving children? *

YES

NO

5. Have you ever been accused, charged or alleged to have committed any act of neglecting, abusing or molesting any child? *

YES

NO

6. Have you ever been subject to any disciplinary action (including discharge) or investigation
by a church, religious or other organization, or by an employer? *

YES

NO

7. Do you have any drug, alcohol or substance abuse problems; or has anyone ever suggested
that you may have a problem? *

YES

NO

8. Have you been concerned that you may have an addiction to pornography; or has
anyone ever suggested that you may have a problem? *

YES

NO

9. Are you practicing a sexual lifestyle that would not be considered scriptural? *

YES

NO

10. Are you currently taking medication for any emotional disorders? *

YES

NO

11. In the past 6 months, have you been hospitalized due to a mental or emotional disorder? *

YES

NO

I understand that to verify my suitability as a volunteer worker for the children’s department, RECHURCH will request a criminal records search. I understand that the personal information will be held confidential by the children’s directors and church leadership. As a volunteer worker in the children’s department of RECHURCH, I agree to observe and abide by the policies and safeguards measures of RECHURCH. *

UNDERSTAND AND AGREE

Date *

MM

DD

YYYY