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United Church of Christ

Penn Northeast Conference

Address 183 South Broad Street, Nazareth, PA, 18064   Phone  (610) 759.0893

Application for Volunteering

St. John's United Church of Christ

Nazareth, PA

Instructions Please complete all of the questions accurately and fully.
Attach additional sheets if needed.

 

Date:                                                                                      

Name:

Street Address:

City:                                                                                                    State:                          Zip:

How long at current address:

Home phone:                                                             Work phone:

Email address:                                              Driver license number:                                     State:

 

For what position are you applying?

 

What interests you about the position for which you are currently applying?

 

 

What has prepared you for the position for which you are currently applying?

 


Volunteer experience: List most recent experiences working with children or youth

Organization:
Duties:
Dates: from to
Contact:
Phone:

 

Organization:
Duties:
Dates: from to
Contact:
Phone:

 

Organization:
Duties:
Dates: from to
Contact:
Phone:

Educational history –list most recent school completed.

Name of school
Address
City                                                                                                     State                           Zip
Type of school
Name of program or degree
Program completed?

Professional/Civic References

Name:
Address
City:                                                                                                                State:                          Zip:
Daytime phone:
How long have you known this person?
Relationship to you:

Name:
Address:
City:                                                                                                                State:                          Zip:
Daytime phone:
How long have you known this person?
Relationship to you:

Personal References

Name:
Address
City:                                                                                                                State:                          Zip:
Daytime phone:                                                                                             Evening:
How long have you known this person?
Relationship to you:

Name:
Address
City:                                                                                                                State:                          Zip:
Daytime phone:                                                                                             Evening:
How long have you known this person?
Relationship to you:

.

 

 

Assurances -- Read and initial each item to signify your agreement to comply with the statement.

___________ I agree to do my best to prevent abuse and neglect among children and youth involved in church activities and services. I agree not to physically, sexually or emotionally abuse or neglect a child or youth.

____________ I agree to comply with the policies for “General Conduct for the Protection of Children and Youth” defined in the Policies for the Protection of Children and Youth from Abuse. I agree to comply with the “Guidelines for Appropriate Affection” with children and youth. In the event that I observe any inappropriate behaviors or possible policy violations with children or youth, I agree to immediately report my observations [see Policy Section IV (2)].

_____________ I acknowledge my obligation and responsibility to protect children and youth and agree to report known or suspected abuse of children or youth to appropriate church leaders and state authorities in accordance with the Policies for the Protection of Children and Youth from Abuse. I understand that the church will not tolerate abuse of children and youth and I agree to comply in spirit and in action with this position.

_____________ I declare: a) I have never been accused of physically, sexually or emotionally abusing a child, a youth or an adult; b) I have never been convicted of a drug/alcohol-related offence; c) I have not had my license suspended or revoked in the last five years due to reckless driving or driving while intoxicated and/or under the influence of a control substance.

 

Acknowledgment, Release and Signature
To the best of my knowledge, the information contained in this application is complete and accurate. I understand that providing false information is grounds for not choosing me for a volunteer position or for my discharge if I have already been chosen.

I authorize any person or organization, whether or not identified in this application, to provide any information concerning my previous education, driving record, criminal conviction record, sexual offender registry or other qualifications for my volunteering. I also authorize St. John’s United Church of Christ, Nazareth PA to request and receive such information.

If chosen, I agree to be bound by the policies and procedures, including but not limited to its Policies for the Protection of Children and Youth from Abuse and Code of Conduct for theProtection of Children and Youth of St. John’s United Church of Christ, Nazareth PA.  I understand that these may bechanged, withdrawn, added to or interpreted at any time, at the sole discretion of and without prior notice to me by St. John’s United Church of Christ, Nazareth PA. 

I also understand that my volunteering may be terminated, or any offer or acceptance of volunteering withdrawn, at any time, with or without cause, and with or without prior notice at the option of St. John’s United Church of Christ, Nazareth PA or myself.

Nothing contained in this application or in any pre-volunteering communication is intended to or creates a contract between myself and St. John’s United Church of Christ, Nazareth PA for volunteering or the providing of any benefit.

I have received a copy of the Policies for the Protection of Children and Youth from abuse.  I have read and understand the above provisions.

 

Signature _____________________________________                   Date __________________