Clergy and Educator Abuse Survivors Empowered!	Prevention

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(Name of Church)

What type of children’s or youth work do you prefer? ________________________________
(Sabbath School teacher, VBS teacher, children’s music program, nursery, coordinator, etc.)

What time commitment can you make? ________________________________________

Are you a member of the Seventh-day Adventist Church? Yes__ No __

How long? _________   How long in this congregation? ________

Where have you attended church in the past five years? ________

What previous work have you done with youth and children? What are your gifts in this kind of work?

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What training have you had for work with children? ____________________________

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What non-church activities have you done involving children? __________________

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List names of other members of this congregation with whom you have a relationship.

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Were you ever the victim of abuse or sexual molestation as a child? Yes__  No__
(You may refuse to answer this question or may discuss your answer in confidence with the pastor rather than answering on this form. Answering yes, or leaving the question unanswered will not automatically disqualify an applicant for work with youth or children.)

Have you ever been accused of sexual misconduct with a minor? Yes__   No__

Do you have any disability that will impair your work with children?   _________________

Education:
Name of High School/ Academy __________________ Degree/Diploma  Yes__  No__
Name of College __________________ Degree/Diploma  Yes__  No__

Where are you currently employed? ___________________ Position ______________

Work Address ______________________________________________________

Previous employment (five years past to current)

____________________________________________________________________

____________________________________________________________________

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Please list two references which are not former employers or relatives who know of your work with minors.

Name _________________________________  Telephone (___)__________

Address ____________________________________________________________

Name _________________________________  Telephone (___)__________

Address ____________________________________________________________

Applicant’s Statement

The information contained in this application is correct to the best of my knowledge. I authorize any references or churches listed in this application to give any information that they may have regarding my character and fitness for working with children or youth. I hereby release any individual, church, or organization from any and all liability for damages which may result to me, my heirs, or family for compliance with this authorization.

Your signature on this form confirms your understanding and agreement that:

In the event allegations of criminal or sexual misconduct arise regarding your conduct while you serve in the above-described capacity (ies), the church will fully cooperate with any investigation.

I further state that I have carefully read the foregoing release and understand the contents thereof and I sign this release as my own free act. This is a legally binding agreement with I have read and understand.