Rosewood Volunteer Background Check Form

New Background Checks are required every 3 years.
This application will be used to help Rosewood Reformed Church provide a safe and secure environment for everyone who participates in the programs of our church. This screening for approval as a worker (both volunteers and paid staff members) in our church will be performed by the appropriate staff member of our church unless the applicant requests that the screening process be handled exclusively and confidentially by one of the pastors or a specified unrelated member of the Administrative Board. All information disclosed on this form will be handled in a confidential manner and will be used only of the purpose of conducting a background check and complying with the requirements of our Child Safety Policy.

Date of Application

FULL LEGAL NAME (First, Middle, Last)

Maiden Name or Other Names Used: (Type N/A if not applicable)

This address will receive a confirmation email

Best Phone

Other Phone

Address, City, Zip

Birthdate

Last 4 Social Security ###-##-

Driver's License Number:

Picture allowed for Website and/or Social Media

Yes No

Rosewood Affiliation

Member Attendee Outside Volunteer

Have you ever participated in, or been accused of, convicted of, or pleaded guilty or no contest to any abuse or any sexual misconduct?

Yes No

Have you ever had a verdict rendered against you in any civil action arising out of any personal act or conduct related to abuse or sexual abuse?

Yes No

Have you ever been convicted of or pleaded guilty or no contest to any criminal offense of any kind?

Yes No

Are you aware of any traits or tendencies you possess that could pose a threat to children or youth?

Yes No

If you have lived at your current address less than 10 years, list your previous addresses below: (this is not optional if you have lived at residence less than 10 years)

Address 1

Address 2

Address 3

Please provide a least two references from places of employment or prior voluntary service. References must be over 18 years of age, must not be a relative, and must have known you for at least one year.

Person 1 Name:

Relationship

How long have you known this person:

Phone

Address

Person 2 Name:

Relationship:

How long have you known this person:

Phone

Address

List your previous experience working with children and youth:

Applicant’s Statement

I hereby represent and warrant that the information contained in this application is correct and complete to the best of my knowledge. I authorize any references, or any other person or organization, whether or not identified in this application, to give you any information (including opinions) regarding my character and fitness for volunteer service.

I agree to be bound by and follow the Code of Conduct and other provisions in the Child Safety Policy of Rosewood Reformed Church. (Click or tap the red text to read.)
This includes my understanding and agreement that all allegations against me of abuse will be reported to the proper authorities.

I authorize and agree to a criminal history check on a state and national level. My typed electronic signature below authorizes the church to make such checks and to disclose the results to the Administrative Board of the Rosewood Reformed Church as needed to make a decision regarding my volunteer service.

I hereby release any individual acting on behalf of Rosewood Reformed Church and the Church itself from any and all liability for damages of whatever kind of nature which may result to me, my heirs, or my family, on account of compliance or any attempts to comply with the Child Safety Policy of Rosewood Reformed Church.

I further state that I HAVE CAREFULLY READ THE FOREGOING RELEASE AND KNOW THE CONTENTS THEREOF AND SIGN THIS RELEASE ON MY OWN FREE ACT. This is a legal agreement which I have read and understand.

By typing your name, you are agreeing to the terms in the agreement above.

Typed Signature (Full Legal Name)

Rosewood Volunteer Background Check Form

Description

Please Fix the Following