Trinity Presbyterian Church of Atlanta, Georgia

Paid Staff/Volunteer Recommitment Form

 

Part I

 

Name (last, first, middle, maiden):                                                                                                                                                         

 

Address:                                                                                                                                                                                                    

 

Sex:   o MaIe     o Female

 

Birthdate:                                               

 

Drivers License Number:                                                                          State:                                    

 

Social Security Number:                                                                        

 

Home Phone:                                                                                         

 

Place of Employment:                                                                                                                                                                           

 

Work Phone:                                                                                          

 

 

Part II

 

Your honest answers to the following questions will assist Trinity in providing the finest care possible.  If you prefer, you may choose to discuss your answers with a member of our pastoral staff rather than using this form.

 

1. Have you ever been subject to any disciplinary action, complaint or allegations that you violated any employer's or any organization's policy concerning sexual misconduct?  o Yes    o No (If yes, please explain)

 

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               

 

 

2. Have you ever been arrested, charged, indicted or convicted for any criminal offense (misdemeanor or felony) other than a traffic violation?  o Yes    o No (If yes, please explain.)

 

 

 

 

3. Have you ever had your driver's license suspended or restricted for any reason?  o Yes    o No (lf yes, please describe the date(s) and reasons for each occurrence.)

 

 

 

4. Have you ever been hospitalized or treated for alcohol or substance abuse?  o Yes    o No (lf, yes, please explain)

 

 

 

 

5. Other than the above questions, is there any fact or circumstance involving you or your background that would cause

   you or the church to have concerns about your being entrusted with the supervision, guidance and care of minors?

   o Yes    o No (If yes, please explain.)

6. Would you like to meet with a member of the pastoral staff regarding the issues listed above or for any other concerns?

     o Yes    o No.

 

    lf yes, and you would prefer a specific staff member, please indicate your choice:                                                                         

 

 

 

 

Part III - Authorization and Release

 

I understand and agree that:

 

A.      All information I have provided may be verified. I agree to release from liability any person or organization that provides information regarding me. I do hereby agree to indemnify and hold harmless, Trinity Presbyterian Church of Atlanta, Georgia, it's employees, representatives and agents from any claims or causes or action relating in any manner to the verification of or attempts to verify the information provided. I understand that any information received will not be disclosed to me, and I hereby waive any right I any have to inspect any information provided about me by any person or organization identified by me on this form.

 

B.       I hereby give my permission for the Trinity Presbyterian Church of Atlanta, Georgia, to obtain information relating to my criminal history record through the appropriate agency. The criminal history record, as received from the reporting agencies may include arrest and conviction data as well as plea bargains and deferred adjudications. I understand this information will be used, in Part, to determine my eligibility for an employment or volunteer position with the church. I also understand that I will have the opportunity to review the criminal history, and a procedure is available for clarification, if I dispute the record as received. I, the undersigned, do for myself and heirs, executors and administrators, hereby release and forever discharge and agree to indemnify the investigating agency and each of their officers, directors, employees, and agents and hold them harmless from and against any and all causes of actions, suits, liabilities, costs, debts and sums of money, claims and demands whatsoever, and any and all related attorney's fees, court costs and other expenses resulting from the investigation of my background in connection with my application to become an employee or a volunteer.

 

C.       I have no past conviction of or pending proceeding addressing an allegation of child abuse or neglect.

 

D.      I acknowledge that I have read the Trinity Presbyterian Church Child And Youth Abuse Prevention Policy, I understand it, and I agree comply with the guidelines set forth in it.  Additionally, I have received a copy of the Child And Youth Abuse Prevention Policy for my personal use.

 

E.       By signing this form, I certify and affirm that the information I have given is true, complete and correct in all respects.

 

 

 

Applicant's Signature:                                                                                                         Date:                                                          

 

 

Please Print Name Here:                                                                                                

 

 

This form is confidential and will be kept in a locked file in the office of Trinity Presbyterian Church of Atlanta, Georgia.