Kid City Volunteer Application Name * First Name Last Name Email * Phone * (###) ### #### Birthdate MM DD YYYY Gender * Male Female Personal History In order to ensure the health, safety, and security of our children, we reserve the right to screen our volunteers. Please check the appropriate answers below so we may discuss how this may impact your serving in Kid City. Health Problems * Do you have any health problems (disabilities, physical limitations, etc.) that might affect your work with children? Yes No Addictions * Have you ever had a problem with drugs, alcohol, pornography, or any other addiction, or, has anyone ever suggested that you may have a problem with any of these things? Yes No Arrest Record * Do you have an arrest record? Yes No If "yes" to any of the above 3 questions, please explain further: Child Abuse * Have you ever been convicted or accused of physical abuse, sexual abuse, neglect, molestation, or exploitation of a minor? Yes No Authenticity, Authorization, and Background Check I authorize Holy Trinity Church or its representatives to make any and all appropriate inquiries regarding my background, and I release the church and its representatives from any liability which may result from such actions. I understand that if I type my name in the spaces below this is a legally binding equivalent of a traditional handwritten signature. The information included in this profile is correct to the best of my knowledge. SSN * Social Security Number is required for background check. Signature * Date * MM DD YYYY Thank you!
