Safe Church - Young Person - 16-17yrs - Screening Form • Mayfield Baptist Church

Safe Ministry Screening Questionnaire

For Volunteers - 16-17yrs

Please Note: This is a sensitive document that must be stored in a confidential manner accessible only by a limited number of authorised persons.

VOLUNTEER PERSONAL DETAILS

Volunteer First Name *

V - DATE OF BIRTH *

V - Street Address *

V - Mobile *

Volunteer Surname *

V - GENDER *

Male

Female

Other

V - Suburb / Postcode

V - Email *

Please outline any health conditions that may affect your volunteer role.

V - Health Conditions

PARENT / GUARDIAN PERSONAL DETAILS

First Name *

Mobile Number *

Home Address *

Home State *

Consent to contact Child by: *

Phone

SMS

None

Last Name *

Email Address *

Home City *

Home Postcode *

Which area/s of ministry are you interested in serving in?

Please make at least one selection from each List

Ministry Areas *

For all Volunteers to complete

Please select either “YES” or “NO” for each of the following questions.

If you answer “yes” to any of the following questions, please submit details on a separate document with your parent/guardian to co-sign

or discuss with a Pastor or the Church Leadership Chair (who holds an equivalent leadership role in our church), with a parent/guardian present.

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 or convicted of a criminal offence? *

Yes

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

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

Church attendance over past 3 years

Other churches you have attended previously - Name and Location *

Date first attended MBC *

Approx dates of Attendance *

List any Roles Held *

Tip: If you didnt have a role - please just note that

Referees

Please provide details of two referees, not related to you, 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.

Please add their Names and Mobile number.

Please also inform them that you have passed their details on, as referees.

SCV - Reference 1 *

SCV - Reference 2 *

CONSENTS & DECLARATION

CONSENT FOR MAYFIELD BAPTIST CHURCH TO HOLD INFORMATION

I consent to the information contained in this application, including any subsequent pages, to be kept by our Church. I understand that this information will be kept in a confidential file and used only for screening purposes.

Information Consent *

Yes

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.

Volunteer Applicant: Please print your name onto form *

Please save a copy of this form to your own files, prior to submitting

V - DATE Entered: *

Both the Young Person Volunteer and the Parent / Guardian must agree with all entries, prior to submission.

Safe Church Team will confrm that a parent/guardian is aware and has contributed to information on the form

Parent / Guardian of Volunteer Applicant - Please print your name on the form *

I understand that by entering my name above, I acknowledge and agree that this electronic record with my name entered, shall be deemed equivalent to a handwritten signature under applicable law, including the Electronic Transactions Act 1999 (Cth) and Electronic Transactions Act 2000 (NSW)

Parent / Guardian - Date Entered *