Safe Church - Adult Screening Form • Mayfield Baptist Church

Safe Ministry Screening Questionnaire

For Staff and Volunteers aged 18yrs and over

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

PERSONAL DETAILS

First Name *

Preferred Name

Middle Name

Last Name *

Previous Names if applicable:

Date of Birth *

Home Address *

Home State *

Mobile Number *

Gender *

Home City *

Home Postcode *

Email Address *

Please Outline any Health Conditions that may affect your volunteer role.

Health Conditions

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

Please make at least one selection from each List

Ministry Areas - List A *

Ministry Areas - List B *

WWCC Information

SCV - WWCC Number *

Do you have or are you prepared to apply for a WWCC number *

SCV - WWCC Expiry Date *

For staff and volunteers in pastoral ministry, leadership or engaged in child-related work or work with vulnerable adults

7. Have you ever had permission to undertake paid or voluntary work with children or other vulnerable people refused, suspended or withdrawn in Australia or any other country? *

Yes

8. Has a child or dependent young person in your care ever been removed from your care by relevant authorities? *

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

Working With Children Check

National Police Check

I Consent to Verification of my WWCC *

Yes

I consent to Providing a National Police Check - (please contact SCT for further information if required) *

Yes

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.

Applicant: Please print your name onto form *

DATE Entered: *

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)

Please save a copy of this form to your own files, before you submit.