CONFIDENTIAL CCC Children & Youth Primary Volunteer Screening   Personal and Ministry Background Last Name First Name Middle Name Address City State Zip Code Home Phone Work Phone Social Security Number Type of Youth or Children's work preferred How long have you been a Christian? Briefly explain your salvation experience Names and addresses of churches attended regularly over the past five years   We are aware that the Body of Christ is made up of many unique people and experiences. Praise God we are all sinners saved by Grace! While it would never be our intention to judge or condemn we believe it is our God-given responsibility (identified in Matthew 18:6) to provide a safe and secure environment for children and youth to participate in our programs and use our facilities. It is equally important that we strive to be a support and help to those who may have certain life-dominating sins in their past. One way to help and support is to allow those individuals to find appropriate ministries within the Body that do not put them in a potentially compromising position. With those redemptive thoughts in mind we ask the following background questions.   Failure to complete any portion of this section openly and honestly will disqualify any member from Nursery Children's or Youth ministries.   List all previous church work involving nursery children or youth (type of work performed and dates): List all previous non-church work involving chldren and youth (list organization's name type of work performed and dates): List any gifts callings training education or other factors that have prepared you for children's or youth ministries: Please list any other pertinent data:   Background Information Have you ever been convicted of pleaded guilty or entered a plea of nolo contendre or a plea amounting to an admission of guilt to a crime other than a minor traffic violation? (If yes please explain.) Have you ever engaged in pedophilia or child pornography? Have you ever engaged in homosexual activity? Are you HIV positive? Are you infected with any other communicable disease? Is there any reason including those related to physical or mental health that might keep you from effectively working with youth or children or that might cause them potential harm?   Personal References (Non-relative) Name Street City State Zip Home Phone Work Phone   Name Street City State Zip Home Phone Work Phone   Name Street City State Zip Home Phone Work Phone Do not enter anything in this field: