Volunteer Application

Statement of Disclosure

For questions 1-6 provide explanations for “Yes” responses. Knowingly providing false information will be grounds for disqualification of application.

Fields marked with an asterisk * are required.

1. Have you ever been convicted of any crime against children or any other persons?*

Yes
No

1. "Yes" Explanation*

2. Do you have any pending charges against you?*

Yes
No

2. "Yes" Explanation*

3. Have you been convicted of the possession, use, or sale of drugs within the last 7 years?*

Yes
No

3. "Yes" Explanation*

4. Have you been convicted of any other misdemeanors or felonies?*

Yes
No

4. "Yes" Explanation*

5. Has your driver’s license been suspended or revoked within the last seven years?*

Yes
No

5. "Yes" Explanation*

6. Have you lived in a state other than New York in the past 7 years?*

Yes
No

6. List States*

Please read thoroughly and sign Confidentiality Agreement and Verification that this Information is accurate.

I affirm that all information provided on this form is accurate to the best of my knowledge.*

Yes
No

I understand that a photocopy or facsimile of this signed document shall be considered as valid as an original.*

Yes
No

I understand that the information from this review process may be shared with the Pastor of Sarah Jane Johnson Memorial United Methodist Church.*

Yes
No

I hereby consent, to and authorize the Conference to conduct the following background checks: criminal records, sex offender registry, and child abuse registry.*

Yes
No

I am willing to have pertinent information shared with Sarah Jane Johnson Memorial United Methodist Church and its ministries. I release the Conference, its employees or volunteers from any and all liability associated with conducting the above background checks.*

Yes
No

I affirm I have no objection to these checks.*

Yes
No

I promise to keep in confidence any information shared with me about children, other volunteers, or any other confidential information shared in the provision of my work. This includes the taking of photographs, discussing personal information, and family information.*

Yes
No

References*

Please list three personal references (people not related to you by blood or marriage) and provide a complete address and phone information for each. References are confidential.

Reference Name	Address	Daytime Phone	Evening Phone	Email	Relationship to reference

Signature

Date

Step 1 of 3

General Information

Qualifications

Statement of Disclosure