Safe Ministry Screening Questionnaire (Under 18yrs) • Mayfield Baptist Church

Safe Ministry Screening Questionnaire (Junior Volunteer)

Surname *

Given Names *

Previous Name/s (If applicable)

Date of Birth *

Gender *

Child's Mobile

Child's Email

Parent/Carer's Name *

Parent/Carer Phone *

Address *

City *

State *

Postcode *

Ministry Involvement

What are of ministry are you wanting to join? *

Do you have any health conditions that we should know about?

Please circle either YES or NO for each of the following questions. If you answer yes to any of the following questions, please give details in the Notes section or discuss with the Pastoral Team Leader or the person holding an equivalent leadership role in your church.

NOTE: A yes answer will not automatically rule an applicant out of selection.

Please note that, if you disclose any potentially criminal actions, the church may need to report this information to the police or other relevant government authorities.

1. Have you ever been charged with and/or convicted of a criminal offence? *

Yes

3. To your knowledge, has there ever been any allegations made against you regarding any abuse of a child, physical abuse or sexual misconduct? *

Yes

5. Have you had a history of alcohol abuse or substance abuse (including prescription, over-the-counter, recreational or illegal drugs)? *

Yes

Notes:

Referees

Please provide details of two referees who are over eighteen years of age and able to give a verbal report on your character and suitability for ministry.Referees may be part of the church.

Referee 1: Name *

Referee 2: Name *

Referee 1: Phone *

Referee 2: Phone *

CHURCHES YOU HAVE ATTENDED REGULARLY IN THE PAST 3 YEARS

Have you been attending Mayfield Baptist for less than 3 years?

Please provide the name, location and dates attended for your previous churches attended in the last 3 years *

Consent for WWCC/Police Check and Information to be Stored

By submitting this form you are consenting to:

* verification of my WWCC number (if required)
* a National Police Check (for staff only)

* the information contained in this application, including any subsequent pages, to be kept by our church (Mayfield Baptist). I understand that this information will be kept in a confidential file and used only for screening purposes.

Declaration

I sincerely declare that:

The information I have provided in this application is true and correct to the best of my knowledge and belief.
I understand that if I provide false or misleading information or withhold relevant information from this questionnaire, the church leadership may determine that I am unsuitable to serve in any role in the church.
I have received a copy of the Code of Conduct and am willing to uphold it.

Submitted By: *

Tip: Please enter your name to confirm acceptance of consents and declaration

Parent Signature *

Tip: Parents may type name as signature.

We may email or call the parent to confirm approval.

Date Submitted *

Date *

Mobile Number

Email Address