Children & Youth Workers Application

Subject: *
E-mail Address: *
First Name *
Middle Name
Last Name *
Date
Present address *
City *
State *
Zip code *
Home phone number
Other phone number
How long have you been a Christian?
Give a brief testimony of how you became a Christian.
Are you a member of Harvest Time Bible Church? *	yes no
How long?
List the names of other churches you have attended regularly during the past 5 years
List all previous church work you have done involving children or youth. (list church name, address/phone number, type of work and dates)
List all previous non-church related work you have done involving children or youth. (list organization name, address/phone number, type of work performed, dates)
List any gifts, calling, training, education or other factors that you feel have prepared you for work with children/youth.
Which type of ministry work do you prefer, children or youth?	children youth
What age?	preschool elementary middle school high school
Have you ever been formally charged, arrested or convicted of or plead guilty to a crime involving child abuse or child molestation, physical abuse of any kind, alcohol or illegal drug use, possession, sale or related offense? *	yes no
If yes, explain.
Have you ever been a complainant or a subject of the Illinois Department of Children and Family Services (DCFS) investigation? *	yes no
If so, what was the nature of the complaint?
What was the outcome?
Explain
Were you a victim of abuse or molestation as a minor? (If you prefer, you may refuse to answer this question. Answering yes, or leaving the question unanswered will not automatically disqualify you as an applicant for youth or childrens work.)	yes no prefer not to answer
Do you have a current drivers license? *	yes no
If yes, has your drivers license ever been suspended or revoked? *	yes no
If so, for what reason?
Explain.
Drivers License Number
Type of license.	passenger CDL air breaks school bus
Would you be willing to drive a bus or van for children/youth events?	yes no perhaps in future but not now
Personal reference#1 as to your character (not former employees or relatives) - list name, address, phone number and relationship
Personal reference#2 as to your character (not former employees or relatives) - list name, address, phone number and relationship


* Required

Applicant's statement:
**this form must be completed and signed at or before your interview**

The information on this application/screening form is correct to the best of my knowledge. I hereby authorize any individual providing references or representatives from any churches listed in this application to give you any information (including opinions) that they may have regarding my character and fitness for youth or children's work. In consideration of the receipt and evaluation of this application by Harvest Time Bible Church, I hereby release nay individual, church, youth organization, charity, employer, reference, or any other person or organization, including record custodians, both collectively and individually, form any and all liability for damages of whatever kind or nature which may at any time result to me, my heirs or family, on account of compliance or any attempts to comply, with this authorization. I waive any right that I may have to inspect any information provided about me by any person or organization identified by me in this application.

Should my application be accepted, I agree to be bound by the Bylaws and policies of Harvest Time Bible Church, and to refrain from unscriptural conduct in the performance of my services on behalf of the church.

I understand that I must meet he eligibility requirements of section 1 of the children's and youth workers policy for Harvest Time Bible Church in order to be eligible to work with youth or children here.

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

Applicant's signature:_________________________________________________________________

Date:_____________________________

Authorization for Background Check:
**this form must be completed and signed at or before your interview**

I hereby give Harvest Time Bible Church authorization to check any records by any agency, company or person which might give pertinent information regarding my suitability to work with children or youth. I release any individual, company, organization or agency from any and all liability in regard to their providing or releasing any such information to Harvest Time Bible Church agents.

Name:(please print)__________________________________________________________________

Address:___________________________________________________________________________

Social security number: __________-_________-_____________

Signature:__________________________________________________________________________

Birth date:_______/________/__________