Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Are you in a healthy spiritual position to mentor young children/teens? *

Yes

No

Date of last tetanus shot *

MM

DD

YYYY

Family Physician Phone *

(###)

###

####

Have you at any time been arrested for any reason, convicted of, or pleaded no contest to any crime? *

Yes

No

Have you at any time engaged in or been accused of any act of child molestation, exploitation, or abuse? *

Yes

No

Verification and Release *

I recognize that the organization to which this application is being submitted is relying on the accuracy of the information contained herein. Accordingly, I attest and affirm that the information I have provided is absolutely true and correct. I authorize the organization to contact any person or entity listed in this application, and I authorize any such person or entity to provide the organization with information, opinions, and impressions relating to my background or qualifications. I voluntarily release the organization and any such person or entity listed herein from liability involving the communication of information relating to my background or qualifications. I further authorize the organization to conduct a criminal background investigation.

Statement of Understanding *

I have carefully read the policy and procedures of the organization, and I agree to abide by them and to protect the health and safety of the children or youth at all times.

Date of Birth

MM

DD

YYYY