Area of service

Office use only

APPLICATION FOR WORKING WITH MINORS

(This form is required every 2 years)

Our church cares about the children and youth in our programs, and desires to ensure their safety while they are in the church’s
supervision. Because we care for children and youth, our church asks any volunteer who will be providing supervision/leadership with
minors to complete this disclosure form. The information obtained on this form is for internal use by Church of the Resurrection only.
Please answer each question below. Your social security number is required. Your responses will be treated confidentially.

Name (Include Middle Initial) ______________________________ Date of Birth (M/D/Y) ____________________

List Any Other Names Used ____________________________________________________________________
Address (Include City, State and Zip) ______________________________________________________________
List previous Addresses (last 10 years) ____________________________________________________________
___________________________________________________________________________________________
Social Security Number ____________________ Email Address _________________________________________
Home Telephone ___________________ Business or Cell phone ________________________________________
Occupation and Current Employer _________________________________________________________________
As a volunteer in KiDS COR, do you agree to observe all church policies regarding working with minors? _____Yes No
Have you ever been convicted of a criminal offense? ______________________________________________ Yes No
Do you have any criminal charges pending? _____________________________________________________Yes No
Have you ever been convicted of child neglect or abuse? ___________________________________________Yes No
Do you have any charges of child neglect or abuse pending? ________________________________________Yes No
In addition to the above, is there any fact or circumstances involving you or your background that would call
into question you being entrusted with the supervision, guidance, and care of children or young people? ____ Yes No
(If yes, explain in detail on a separate page, including dates and locations)

Do you have a driver’s license? Yes No List the state and driver’s license number _____________________

List two references, other than family members, who are familiar with your character as it relates to working with minors.
(Name/Address/Telephone Number/Relationship)

1.__________________________________________________________________________________________
2.__________________________________________________________________________________________
List the churches you have attended regularly for the last several years. (Name and Location)

___________________________________________________________________________________________

___________________________________________________________________________________________

List all organizations through which you have volunteered with minors in the past 5 years. (Include Location)

___________________________________________________________________________________________

___________________________________________________________________________________________

The information that I have provided may be verified by contacting persons named in this application, or by
contacting any person or organization that may have any information concerning me. I hereby release and agree to FOR OFFICE USE ONLY
hold harmless from liability any person or organization that provides information. I also agree to hold harmless the The Church of the
Church of the Resurrection, and its paid staff members and volunteers. I waive any right to inspect any information Resurrection is unaware of
provided about me by any person, organization, or investigative agency. In signing this application, I agree to be any information contrary to the
guided by the policies and regulations of Church of the Resurrection. I affirm that the information I have given on this information stated on this
form is true, correct and complete. application.

Action Taken _____________

Approved by _____________
____________________________________________________________
Signature of Applicant Date Date ___________________
Please complete the reverse side of this application. Member ____ Lanyard _____
Entered in Arena _____

Revised 7/2010
Have you volunteered within Children’s Ministries before? Yes No

If yes, what was your most recent date of participation?__________________________

Do you have a KiDS COR lanyard/name tag? Yes No

If no, how do you want your name to read on your KiDS COR lanyard/name tag?

Where are you serving? (Please circle area and time if listed)

• Saturday Evening Nursery (Infant – Age 2)

• Saturday Evening Early Childhood Guide (Age 2-Pre-K)

• Sunday Evening Nursery (Infant – Age 2)

• Sunday Evening Early Childhood Guide (Age 2 - Pre-K)
• Sunday Evening (K – 5th Grade)

• Sunday Morning Nursery (infant-Age 2) 9:00 or 10:45

• Sunday Morning Early Childhood Guide (Age 2-Pre-K) 9:00 or 10:45
• Sunday Morning Elementary Guide (K-5th Grade) 9:00 or 10:45

• Information Booth Sat. 5 Sun. 9:00 or 10:45 Sun. 5

• Greeter Sat. 5 Sun. 9:00 or 10:45 Sun. 5
• Drama Team Sat. 5 Sun. 9:00 or 10:45 Sun. 5
• Sound Booth Sat. 5 Sun. 9:00 or 10:45 Sun. 5
• Music Team Sat. 5 Sun. 9:00 or 10:45 Sun. 5
• Parent helper Sat. 5 Sun. 9:00 or 10:45 Sun. 5
• Summer Classroom Helper Sat. 5 Sun. 9:00 or 10:45 Sun. 5
• Christmas Eve Nursery
• Easter Nursery
• Special events – Family Advent Night 3rd Grade Bible VBC Youthfront
• ZONE
• W.I.L.D. 1s
• Summer Sports Camp
• Bin Babe
• Photographer or Filming
• Puppets
• Library

Please return this form to your program director or a KiDS COR Ministry Connector:
Stacy Furey 232-4194 or stacy.furey@cor.org Fax: 544-0799
Revised 7/2010