Volunteer Application - Deep River First Congregational Church

APPLICANT INFORMATION

Because we care about our congregation, it is the policy of the First Congregational Church of Deep River for adult staff and volunteers to fill out this form and have a Criminal Offender Record Information and Sexual Offender Record Information check performed if requested.

Full Name*

Email Address

Date of Birth*

Cell Phone*

Home Phone (if applicable)

Physical Street Address*

Street Address Address Line 2 City State ZIP Code

Is your mailing address different than your street address?*

Yes

No

Mailing Information

Mailing Address*

Mailing Address Mailing Address Line 2 City State ZIP Code

Are you a member of this church?*

Yes

No

If yes, how long? (at least 6 month waiting period required)

If no, list name and town of previous church(es) attended within the past five years

Professional training, skills, hobbies that might relate to the volunteer position

List other volunteer experience

Do you have any special Certifications (i.e. CPR, First Aid, etc.)*

Yes

No

If yes, please indicate

EMPLOYMENT INFORMATION

Current Employer Name (if employed for less than one year, please list previous employer below)

Occupation

Employed Since

Employer's Phone number

Employer Address

Street Address Address Line 2 City State ZIP Code

Previous Employer & address (if current employer is less than one year)

Driving Information

Do you have a valid driver's license?*

Yes

No

Driver's License No.

State

Have you ever been convicted of, or plead guilty or no contest to any crime(s) - (e.g. felony or misdemeanor including DWI, DUI, but not including minor traffic violations or any convictions as a youthful offender)?*

Yes

No

If yes, describe each in full including place, date, disposition of conviction. A conviction will not necessarily affect your acceptance as a volunteer. NOTE: You are not required to disclose the existence of any arrest, criminal charge or conviction, the records of which have been erased pursuant to Sections 46B-146, 54-760 or 54-1452a of the CT General Statues.*

References

Please list three references, at least one of which has knowledge of your participation as a volunteer in a church, religious or school organization. No more than one reference should be a staff/member of this congregation and no reference should be a relative.

Reference 1 - Name*

Reference 1 - Phone Number*

Reference 1 - Relation*

Reference 2 - Name*

Reference 2 - Phone Number*

Reference 2 - Relation*

Reference 3 - Name*

Reference 3 - Phone Number*

Reference 3 - Relation*

EMERGENCY CONTACT INFORMATION

Emergency Contact Name*

Phone Number*

Relation*

APPLICANT'S STATEMENT

The information contained in this application is correct to the best of my knowledge. As a condition of employment or volunteering, I give permission for the First Congregational Church, Deep River, CT to conduct a background check on me, which may include a review of sex offender registries, and child abuse and criminal-history records. Background check will be reviewed and retained for three years. I understand that my staff position or volunteer duties at the First Congregational Church, Deep River, CT - in particular my interaction with children, youth and other vulnerable population - is conditional on the church receiving no inappropriate information or opinions on my background from the references listed here. I waive any right to inspect any information provided about me by any person/organization identified by me in this application. I release and agree to hold harmless from liability the First Congregational Church, Deep River, CT. I have carefully read the foregoing release and know the contents and I sign this release as my own free act.

Applicant's Name*

Date*

FORM REVIEW

The Application for Volunteer Service for Youth Activities is valid for three years. If at any time the above information changes, a new application must be submitted. This form will be reviewed and retained by the Director of Christian Education.

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