Child Protection Form

Personal Information

Name:

Middle Name:

Maiden Name:

Other Names:

Date of Birth:

Gender:

Male Female

Current Address:

Previous Address 1:

Previous Address 2:

Have you ever lived outside the USA?

Yes No

Home Phone:

Cell Phone:

Email:

This address will receive a confirmation email

Current Employer:

Employer's Phone:

Have you ever been charged or convicted of any act of neglecting, abusing, molesting, assaulting or any type of sexual misconduct against any child or adult?

Yes No

If yes, explain:

Is there any circumstance or pattern in your life which would make it inappropriate for you to serve at IBC?

Yes No

If yes, explain:

Agreement 1

The information contained in this screening form is correct to the best of my knowledge. I authorize any references listed on this application to give IBC any information (including opinions) that they may have regarding my character and fitness for children's work. In consideration of the receipt and evaluation of this screening, I hereby release any individual, church, youth organization, employer, charity, reference, or any other person or organization, both individually or collectively, from any and all liability for damages of whatever kind or nature which may at any time result to me, my heirs or my family on account of compliance or any attempts to comply with this authorization, excepting only the communication of knowingly false information.
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 screening form. As a volunteer or paid worker for Immanuel Baptist Church I agree to abide by the Child Protection Policy and to refrain from unscriptural conduct in the performance of my services on its behalf.
I have read the Child Protection Policy Handbook and agree to follow the policies and procedures in handling any child abuse situations that may arise.

Agreement 2

I further state that I have read carefully the foregoing release and know the contents thereof. This is a legally binding agreement which I have read and understand.
In connection with my future involvement as a staff member or a volunteer, I understand that IBC may conduct a background check to determine my ability to minister in this role. It may include information concerning my character, work habits, performance and any court records that may have a bearing on my job responsibilities.
I acknowledge that a telephonic facsimile (fax) or photocopy shall be as valid as the original.
I hereby authorize, without reservation, any law enforcement agency, institution, information service bureau, school, employer, church or non-profit organization, reference, or insurance company contacted by IBC or its consumer reporting agency or its agents, to furnish the information described above.
I understand that if any of those records contains information which is used to deny my service by Immanuel Baptist Church, that I will be notified of my rights and where I can obtain a copy of the information.

Approval

I further state that I have read carefully the foregoing release and know the contents thereof. This is a legally binding agreement which I have read and understand. By entering my name in the box below, I am providing my digital signature on this form.

Electronic Signature:

Date:

Parent or Guardian Signature if under 18:

Date:

Spiritual Information

Are you a member of Immanuel Baptist Church?

Yes No

Are you a regular attendee of Immanuel Baptist Church?

Yes No

If “NO”, of which church are you a member/attendee?

Why are you interested in serving at IBC?

What would you say to God if He were to ask you, “Why should I let you into My heaven?”

Are you willing to submit to the decisions of the leadership of IBC?

Yes No

Are you willing to support the doctrine and policies of IBC?

Yes No

Are you committed to living according to Biblical principles?

Yes No

Have you read and understood the IBC Child Protection Policy?

Yes No

Please list your previous experience working or volunteering with people 0–18 years of age or adults with disabilities over the last 10 years. Include the organization’s name and location (city and state) and the work you performed.

What area(s) and with which age group(s) do you plan to serve?

Approval

By checking this box, I am indicating that the above information is accurate and I agree to the terms and conditions stated in the description of this form. By entering my name in the box below, I am providing my digital signature on this form.

Electronic Signature:

Date:

Child Protection Form

Description

Please Fix the Following