Name *

First Name

Last Name

Home Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Birth Date *

MM

DD

YYYY

Sex *

Male

Female

Cell Phone Number *

(###)

###

####

Are you physically able to perform the duties of the position for which you are applying? *

Yes

No

Do you have any medical or physical conditions that we need to be aware of? *

Yes

No

Name *

First Name

Last Name

Home Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Do you have a passport? *

Yes

No

Birth Date *

MM

DD

YYYY

Sex *

Male

Female

Cell Phone Number *

(###)

###

####

School/College Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

2. Have you ever been convicted of any crime relating in any manner to children and/or your conduct with them? *

Yes

No

3. Have you ever been convicted of any crime including, but not limited to, those listed below and/or any crime similar in any manner to those listed below: *

• Indecent assault and battery on a child under fourteen • Indecent assault and battery on a mentally retarded person • Indecent assault and battery on a person who has obtained the age of fourteen • Rape • Rape of a child under sixteen with force • Assault with intent to commit rape • Kidnapping of a child under sixteen with intent to commit rape • Distribution and trafficking of narcotics or other controlled substances • Intent to commit any of the above crimes

Yes

No

4. Have you ever been judged liable for civil penalties or damages involving sexual or physical abuse of children? *

Yes

No

5. Are you now or have you ever been subject to any court order involving sexual or physical abuse of a minor, including, but not limited to a domestic order or protection? *

Yes

No

6. Have your parental rights ever been terminated for reasons involving sexual or physical abuse of children? *

Yes

No

N/A

I understand that (please check each box below) *

A. Hope Church may deny employment to any person who answers “yes” to any one of questions 2-6.

B. If hired and the employer later discovers circumstances that would indicate a “yes” answer to any of the above questions, employment may be terminated immediately.

C. The information provided on this form is subject to verification, which may include a criminal history check and request from any Central Registry of child abusers.

D. Hope Church may terminate employment or volunteer service of any person if that person is found, regardless of when discovered to: 1) have a history of complaints of abuse of a minor; 2) have resigned, been terminated or been asked to resign from a position whether paid or unpaid, due to complaint(s) of sexual abuse of a minor; and/or 3) have falsified or omitted information in this disclosure statement.

E. This disclosure statement must be updated yearly.

Date *

MM

DD

YYYY

This reference is for *

Applicant please print your name here

First Name

Last Name

Please check all that apply

I request that this recommendation be treated as confidential to Hope Church.

I understand that it will be used solely for the decision of my application to Hope Church.

I waive the right to view this reference form at any point in the future:

E-Signature *

First Name

Last Name

Date *

MM

DD

YYYY