Perimeter Logo

xArchive - Application for all working w minors

Thank you for your interest in serving in one of our ministries for children or youth.  At Perimeter Church, we take our responsibility to maintain a safe and secure environment for our children and youth very seriously.  The purpose of this form is to assist in creating this safe and secure environment for all of our children or youth who participate in the programs of Perimeter Church.

SUGGESTIONS FOR COMPLETING THIS FORM:
1) PREPARE IN ADVANCE: The Application must be completed in a single sitting since it is not possible to save a partially completed application. So before you begin, please scroll through the form and make sure you have all of the necessary information (ex. references) collected and prepared to be entered.
2) HARDWARE/SOFTWARE: Complete on a computer (Chrome or Firefox, if possible) as opposed to a handheld device.

*Address Line 1
Address Line 2
*City
*State/Province/Region
*Zip/Postal Code
*Gender:
*Date of Birth:
*Marital Status:
Spouse's Name, if applicable:
*Number of children, if applicable:
Ages of Children, if applicable:
Present Employer, if applicable:
Employer Phone, if applicable:
*What ministry are you applying for:
CHURCH PARTICIPATION
*How long have you regularly attended Perimeter Church:
*Are you a participating member of Perimeter Church:
If YES, how long:
If NO, which church are you a member:
*Are you in a small group at Perimeter Church:
*Have you completed TFL (Theological Foundations for Leaders):
*Do you have a personal relationship with Jesus Christ:
*Briefly describe your spiritual journey, including when you became a Christian:
*List Perimeter Church ministries in which you are involved:
*What age group do you want to serve:
*Why do you want to work with this age group at Perimeter Church:
*List the name and addresses of other churches you have attended regularly during the past five years:
*List all previous church and non-church work involving minors (list each church/organization's name, location, type of work and dates):
*What is your philosophy concerning re-direction or discipline of children:
*When you are unhappy, angry or emotional about a person or circumstance, what do you do:
SAFETY FORM
The questions below are part of the process to help provide a safe and secure environment for our children/youth.  We understand that the answers to these questions may be private and deeply personal, and we will protect your privacy.
*Have you had any experiences that might make it difficult for you to minister to children/youth at Perimeter:
*Have you been accused or convicted of the use or sale of illegal drugs within the last 5 years:
*Are you currently using illegal drugs:
*Have you ever been hospitalized, treated for, or struggled with alcohol or substance abuse:
*Have you ever been charged with a misdemeanor or felony:
*Have you ever physically or sexually abused a child:
*Have you ever been accused or arrested for sexual molestation or physical or emotional abuse of child:
*Do you consider yourself to have been physically or sexually abused as a child:
*Have you experienced any significant physical or emotional stresses within the past year, such as the loss of a parent, spouse, or child; extreme ill health; or any emotional or physical crisis:
*Have you ever been denied legal custody of your child(ren) in any legal proceedings including divorce decrees or settlements:
*Are you currently engaged in any conduct or life pattern for which you are unrepentant or unwilling to stop:
*Do you have any health issues that could place the children of Perimeter at risk:
Currently, or in your past, have you struggled with, been advised to receive treatment, or received medical or psychological treatment for:
*Eating Disorders:
*Pornography:
*Emotional Breakdown:
*Divorce:
*Sexual, Physical or Emotional Abuse:
*Suicidal Tendencies:
*Psychological Disorders, such as depression:
*Bipolar Disorder:
If you answered yes to any of the questions above in the Safety Form section, please explain. 
REFERENCES
Each applicant must submit the names and phone numbers of at least one personal reference, one professional reference, and one family member. Additional professional references may be submitted if deemed helpful by applicant in allowing Perimeter Church to determine applicant's fitness for volunteer position and qualifications. The professional references should be familiar with the quality of the individual's work. One of these references should be a person of the opposite sex.
*Reference 1: Personal (Friend):
*City & State of Residence:
*Telephone:
*Email Address:
*Reference 2: Professional Employer (If no employer, give volunteer work reference or additional personal reference):
*City & State of Residence:
*Telephone:
*Email Address:
*Reference 3: Family Member:
*City & State of Residence:
*Telephone:
*Email Address:
SERVING POLICY AND RELEASE STATEMENT
Please review the Statements below in the Agreed Code of Conduct.

I declare that all statements contained in my Application above are true.  I understand that any misrepresentation or omission is cause for dismissal from any program involvement.

*Agree:

I understand that my references and contact from prior volunteer or employment with children, students or disabled adults may be contacted and that an appropriate criminal background check will be conducted.  I authorize Perimeter Church to undertake a criminal background check of my past.

*Agree:

I understand that I must be interviewed and screened before I begin service as a volunteer in Perimeter Church children's/student's programs or ministries.

*Agree:

I understand that I can withdraw from the application process at any time.

*Agree:

I understand that Perimeter Church has a policy of ZERO TOLERANCE FOR ABUSE and takes all allegations of abuse seriously.   I further understand that Perimeter Church cooperates fully with the authorities to investigate all cases of alleged abuse.  Abuse of any kind is grounds for immediate dismissal from my volunteer position and may result in criminal charges.

*Agree:

I am not a pedophile or child molester.  I have not perpetrated physical abuse, sexual abuse, emotional abuse or neglect against a child, student or disabled adult, and I have never been accused of these acts.

*Agree:

I understand and agree that false statements regarding past conduct and/or present situations may be grounds for termination of any volunteer position, and failure to reveal the contents of a sealed criminal record will result in the automatic denial of the application and opportunity to serve as a volunteer.

*Agree:

If accepted as a volunteer, I agree to read and abide by all Policies and Procedures provided to me by Perimeter Church.

*Signature Name:
*Signature Date:
Please review and sign the Release Statement
I authorize Perimeter Church to contact all individuals, organizations, and references listed on the Application and Safety Form in order to verify the information I have provided.  I agree to release from liability any person or organization that provides information related to me, including those persons I have listed as references, as well as contact persons from my previous volunteer work or employment with children. I specifically authorize Perimeter Church to undertake a criminal background check concerning my past. I understand and agree that any information received from the background check and application verification will not be disclosed to me except as required by law, and I hereby waive any right I may have to inspect any information provided about me by any person or organization identified by me on this form. By signing this form below, I certify and affirm that the information I have given on this form is true, complete and correct in all respects.
*Signature Name:
*Signature Date:
Submit Form