Please indicate your areas of interest (for example, Nursery, Noah's Ark Preschool, Faith Forest, Time for Children, VBS, Cross Trainers, Confirmation mentor, TUXIS) *

Full Given Name (First, Middle, Last): *

Email *

Phone Number *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Previous Address (if lived at current address less than 3 years)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth *

YYYY

Social Security Number (to be used ONLY for background check) *

If you would prefer that we call you for your SSN at the time the background check is run, please enter "call me at" and provide the best phone number at which to reach you.

Employer

Occupation

List your children (if any) and their ages *

How long have you attended services or been involved with First Presbyterian Church of La Grange? *

Please list any previous work involving children and/or youth *

What qualities do you have that would help you in your volunteer work? *

Have you read and do you agree to abide by the First Presbyterian Church of La Grange Children and Youth Protection Policy and Procedures? *

Yes

Have you ever participated in, been accused of, pled guilty/no contest to, or been convicted of abuse or any sexual misconduct? *

Yes

If yes, give details:

Have you ever been convicted of, or pled guilty/no contest to a crime? *

Yes

If yes, give details:

Has any civil lawsuit against you alleging actual or attempted sexual discrimination, sexual harassment, sexual exploitation, sexual misconduct, physical abuse or child abuse ever been filed? *

Yes

If yes, please give details and describe resolution of the lawsuit.

Have you ever terminated your employment, professional credentials or service in a volunteer position, or had your employment, professional credentials or authorization to hold a volunteer position terminated, for reasons relating to allegations of actual or attempted sexual discrimination, sexual harassment, sexual exploitation, sexual misconduct, physical abuse or child abuse? *

Yes

If yes, give details:

Do you have a valid driver’s license? *

Yes

Have you ever had your driver’s license suspended or revoked due to reckless driving or driving while intoxicated or under the influence of a controlled substance? *

Yes

If yes, give details:

Please give two references, at least one of whom is not a FPCLG member. *

First Name

Last Name

Address *

Email *

Cell Phone *

(###)

###

####

Other Phone

(###)

###

####

Second Reference *

First Name

Last Name

Address *

Email *

Cell Phone *

(###)

###

####

Other Phone

(###)

###

####

The information contained in this application is true and complete to the best of my knowledge. I authorize investigation of all information contained in the application. The church may also contact my references, and I waive any right to inspect these references. I authorize obtaining information concerning my education, my character and fitness for working with children. I authorize First Presbyterian Church of La Grange to perform a criminal background check now and as needed in the future. I release and hold harmless all parties from all liability for any damage that may result from the release of this information to First Presbyterian Church of La Grange. *

I agree.

Signature *

Please type your full name to electronically sign that you agree to the statement above.

Date *

YYYY

Thank you!