Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Please indicate if any of the following apply to you:

You have had, or been concerned that you might have, an addiction to drugs, alcohol, pronography, or any other substance that might hinder your ability as a children's ministry volunteer.

You have ever been arrested for, convicted of, or pleaded guilty to a crime (misdemeanor or felony), or have had a charge expunged.

You have ever been accused, charged, or alleged to have committed any act of neglecting, abusing, molesting, or battering any child or adult.

You have been personally sued.

You have been treated for a psychiatric disorder.

You have any life circumstance that would make it inappropriate for you to serve with minors and/or that would compromise the integrity of Christ Covenant Church.

REFERENCE #1 Name *

First Name

Last Name

Phone

(###)

###

####

REFERENCE #2 Name *

First Name

Last Name

Phone

(###)

###

####

REFERENCE #3 Name *

First Name

Last Name

Phone

(###)

###

####

When are you available to serve?

Check all that apply.

Sunday morning

Sunday evening

Weekend special events

Weeknight special events

Weekday special events

Date Signed *

MM

DD

YYYY