Stewartstown United Methodist Church

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Stewartstown U.M.C.

Safe Sanctuary Volunteer Application

Individual Information (required of all who would work with children or youth):

Name: ________________________________________________________

Address: ______________________________________________________

Daytime phone: _________________________________________________

Evening phone: _________________________________________________

What volunteer position(s) or area(s) of service interest  you  at Stewartstown UMC?

______________________________________________________________________________

Occupation:  ___________________________________________________________________

Employer: _____________________________________________________________________

Current job responsibilities and schedule at your place of work :   ____________________________

______________________________________________________________________________

Previous work experience: __________________________________________________________

Previous volunteer experience: ______________________________________________________

Special interests, hobbies, and skills: _________________________________________________

How many hours per week are you available to volunteer at SUMC? ________________________

Days______________ Evenings _________________Weekends ________________________

Do you have your own transportation? ______________________________________________

Do you have a valid driver's license? ________________________________________________

Do you have automotive liability insurance?(list policy limits and name of carrier if you might ever

transport children or youth in  a SUMC activity) _________________________________________

Why would you like to volunteer as a worker with children and/or youth?______________________ ______________________________________________________________________________

What qualities do you have that would help you work with children and/or youth?

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Have you ever been charged, convicted of, or pled guilty to a crime, either a misdemeanor or a felony (including but not limited to drug-related charges, child abuse, other crimes of violence, theft,  including motor vehicle violations)? ___ No ___ Yes If yes, please explain fully:

_____________________________________________________________________________

Would you be available for periodic volunteer training sessions at SUMC in Safe Sanctuary procedures?

___ Yes ___ No

If you have ever been exposed to an incident of child abuse or neglect you are encouraged to talk with the Senior Pastor, who has resources that may be of help to you.

References:

Please list three personal references (people who are not related to you by blood or marriage) and provide a complete address and phone information for each. References are confidential.

1. Name: _____________________________________________________________________

Address: _____________________________________________________________________

Daytime phone: ________________________Evening phone:  __________________________

Relationship to reference: ________________________________________________________

2. Name: _____________________________________________________________________

Address: _____________________________________________________________________

Daytime phone: ________________________Evening phone:  __________________________

Relationship to reference: ________________________________________________________

3. Name: _____________________________________________________________________

Address: _____________________________________________________________________

Daytime phone: ________________________Evening phone:  __________________________

Relationship to reference: ________________________________________________________

 I give my permission for Stewartstown UMC to contact the persons who I have given as references.

_____________________________________________________

Signature of Applicant                                       Date

June 30, 2003

Please complete and turn in to the Sr. Pastor