KMAK
This application is to be completed by all applicants for any position (whether paid or not) if the
position involves working with minors. This is not an employment application. This form is part of
our effort to provide a safe environment for children and your involvement in our programs. The
information you provide will be held in the strictest confidence and will not be disclosed beyond what
is reasonably necessary or legally required.
I.
PERSONAL
INFORMATION:
Full legal name:
________________________________________________________________
Address: ______________________________________________________________________
Phone Number: ____________________ Social Security #
________ - ________ - __________
Have you ever used or been known by any aliases?
____________________________________
If so, what other name might you have gone by or be
known by? _________________________
Why did you use an alias?
_________________________________________________________
_______________________________________________________________________________
If you have not lived at your present address for
five years or longer, please list a prior address:
Address:
_______________________________________________________________________
From Calendar Date: _____________________ to
______________________________________
II.
CHURCH
WORK HISTORY:
Name of church where you
hold membership: _________________________________________
Denomination:
___________________________________________________________________
Church address:
__________________________________________________________________
Pastor’s Name:
___________________________________________________________________
Dates as Member: from
____________________ to _____________________________________
What work did you perform
with children or youth? ______________________________________
________________________________________________________________________________
________________________________________________________________________________
Prior church where you held
membership: _____________________________________________
Denomination:
____________________________________________________________________
Church Address:
__________________________________________________________________
Pastor’s Name:
___________________________________________________________________
Dates as Member: from
_________________________ to: ________________________________
What work did you perform with
children or youth? ______________________________________
________________________________________________________________________________
________________________________________________________________________________
III.
PRESENT
EMPLOYMENT:
Name of Employer:
________________________________________________________________
Address:
_________________________________________________________________________
Starting date:
_____________________________________________________________________
Did work involve
youth/children: ______________________________________________________
Type of work performed:
____________________________________________________________
Immediate Supervisor:
______________________________________________________________
IV.
CHARACTER
REFERENCES
(Do not list relatives or former employers)
Name:
___________________________________________________________________________
Address:
_________________________________________________________________________
Phone Number:
__________________ How long known: __________________________________
Relationship to you
___________________ Occupation: ___________________________________
Name:
___________________________________________________________________________
Address:
_________________________________________________________________________
Phone Number
___________________ How Long known: __________________________________
Relationship to you:
___________________ Occupation: ___________________________________
V.
PERSONAL
QUESTONS:
During your lifetime, have you ever been accused of molesting or abusing a child, or accused of physical assault or sexual offenses of any nature? Yes _______ No _______.
If yes, please explain the
nature of the accusation, charge or conviction (this information will be
protected and kept
confidential). ______________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
As a child or teenager were you ever molested, abused,
assaulted, or subjected to a sex offense of any
Nature? Yes ________ No
________.
I hereby certify that I have read the above and
foregoing application form. My answers
are
true and correct to the best of
my knowledge. If I am allowed to work
with children or youth,
I agree to be bound by the Bylaws and policies of
from unscriptural conduct in the
performance of services to the Association.
_______________________________________________
Please sign your full legal name
Dated:
________________________________