APPLICATION FOR WORKING WITH MINORS

Our church cares about the children and youth in our programs, and desires to ensure their safety while they are in the church’s supervision.
Because we care for children and youth, our church asks any volunteer who will be providing supervision/leadership with minors to complete this
disclosure form. The information obtained on this form is for internal use by Church of the Resurrection only. Please answer each question
below. Your responses will be treated confidentially.
confidentially.

Name (Include Middle Initial) _______________________________ Date of Birth (M/D/Y) _________________

List Any Other Names Used __________________________________________________________________

Address (Include City, State and Zip) ____________________________________________________________

List previous Addresses (last 10 years) ____________________________________________________________

_________________________________________________________________________________________

Social Security Number ____________________ Email Address _____________________________________

Home Telephone ___________________ Business or Cell phone _____________________________________

Occupation and Current Employer_______________________________________________________________

As a volunteer in KiDS COR, do you agree to observe all church policies regarding working with minors?______Yes No
Have you ever been convicted of a criminal offense? ______________________________________________Yes No
Do you have any criminal charges pending?_____________________________________________________Yes No
Have you ever been convicted of child neglect or abuse? ___________________________________________Yes No
Do you have any charges of child neglect or abuse pending?_________________________________________Yes No
In addition to the above, is there any fact or circumstances involving you or your background that would call into question
your being entrusted with the supervision, guidance, and care of children or young people? (If yes, explain in detail on a separate
page, including dates and locations)____________________________________________________________Yes No
Do you have a driver’s license? Yes No List the state and driver’s license number ____________________________
List two references,
references other than family members, who are familiar with your character as it relates to working with minors.
(Name/Address/Telephone
Name/Address/Telephone Number/Relationship)
Number/Relationship
Example: Ruth Resurrection 13720 Roe Ave, Leawood, KS 66224 (913)-544-0757 neighbor
1. ________________________________________________________________________________________

2. ________________________________________________________________________________________

List the churches you have attended regularly for the last several years. (Name and Location)
_________________________________________________________________________________________
_________________________________________________________________________________________
List all organizations through which you have volunteered with minors in the past 5 years. (Include Location)
_________________________________________________________________________________________
_________________________________________________________________________________________
FOR OFFICE USE ONLY

The information that I have provided may be verified by contacting persons named in this application, or by contacting The Church of the Resurrection is
unaware of any information
any person or organization that may have any information concerning me. I hereby release and agree to hold harmless contrary to the information stated
from liability any person or organization that provides information. I also agree to hold harmless the Church of the on this application.
Resurrection, and its paid staff members and volunteers. I waive any right to inspect any information provided about me
Action Taken _______________
by any person, organization, or investigative agency. In signing this application, I agree to be guided by the policies and
Approved by _______________
regulations of Church of the Resurrection. I affirm that the information I have given on this form is true, correct and
Date ______________________
complete.
Member ________ Lanyard ___
__________________________________________________________
Entered in Arena ________
Signature of Applicant Date
Please complete the reverse side of this application.
Have you volunteered within Children’s Ministries before? Yes No

If yes, what was your most recent date of participation?__________________________

__________________________

Do you have a KiDS COR lanyard/name tag? Yes No

If no, how do you want your name to read on your KiDS COR lanyard/name tag?

Where are you signing up to serve? (please circle one)

• Saturday Evening (Infant – Age 2)

• Saturday Evening Early Childhood Guide (Age 2-Pre-K)
• Sunday Evening (Infant – Age 2)
• Sunday Evening Early Childhood Guide (Age 2 - Pre-K)
• Sunday Evening (K – 5th Grade)
• Sunday Morning Early Childhood Guide (Age 2-Pre-K) 9:00 or 10:45
• Sunday Morning Elementary Guide (K-5th Grade) 9:00 or 10:45
• Information Booth
• Greeter
• Nursery
• Drama Team
• Music Team
• Special Events
• Vacation Bible Camp
• ZONE
• W.I.L.D. 1’s

Please return this form to your program director or a KiDS COR Ministry Connector:
Christina Bradshaw 544-0293 or christina.bradshaw@cor.org for the nursery.
Stacy Furey 232-4194 or stacy.furey@cor.org for all others.