First Name: *

 
Middle Initial:

 
Last Name: *

 
Phone Number: *

 
Street Address:

 
City:

 
State:

 
Zip Code:

 
If you have lived at your current address less than seven years, please provide information on all addresses during that period:

 
List all other names by which you have ever been known:

 
Date of Birth:

 
Driver's License #:

 
Length of membership/attendance at Bachelor Creek: *

 
T-Shirt Size: *


 
Emergency Contact Name:

 
Relationship to Emergency Contact:

 
Emergency Contact Phone Number:

 
Are you 18 years of age or older? *

     
 
Have you ever been convicted of, pled guilty to, or pled no contest to a crime other than a minor traffic violation? *

     
 
If you answered "Yes" to the previous question, please explain:

 
REFERENCES:
(Required for mentors and substitute mentors.  Optional for prayer partners, unless they will be having regular contact with children.)

List at least two references from places of employment or prior volunteer service, especially concerning previous work with youth.  References must meet the following criteria: must be over age 18; must not be a relative; must have known you for at least one year.

 
Reference #1 Name:

 
How do you know this person?

 
Length of time you've known this person:

 
Reference #1 Address:

 
Reference #1 Phone Number:

 
Reference #2 Name:

 
How do you know this person?

 
Length of time you've known this person:

 
Reference #2 Address:

 
Reference #2 Phone Number:

 
If you have someone in mind to be your Prayer Partner, please list them here:

 
Please list times available on days below:

 
Monday:

 
Tuesday:

 
Wednesday:

 
Thursday:

 
Friday:

 
Please list previous volunteer activities:

 
Do you have any additional comments/questions/concerns you'd like to share with us?

 
Volunteer Pledge:

If I am assigned as a school volunteer, I accept the responsibility to serve in support of the educational program and supplement the work of the professional staff under their guidance.  I understand that it is important to be reliable, channel suggestions constructively, keep information confidential, and comply with school rules.  As a member or regular attendee of this church, I agree to be accountable to the leadership of this church regarding my Christian life and witnesses according to the biblical witness of this church and in all aspects of conduct and performance related to this volunteer position.

I hereby represent and warrant that the information contained in this application is correct and complete to the best of my knowledge.  I authorize any references, or any other person or organization, whether or not identified in this application, to give you any information (including opinions) regarding my character and fitness for volunteer service.  I understand that a very positive benefit, when working with children, is the relationship developed between the volunteer and child.  I take seriously the relationship that will be formed.  I agree to a criminal history check (national and/or state level).  My signature on this form authorizes you to make such checks and to disclose results to both church and school personnel as part of the KIDS HOPE USA program.

 
Digital Signature of Applicant (please type your name to verify your Volunteer Pledge):

 
Date:

 
Please fill out the background check located on The Kid's Hope page of bachelorcreek.com.

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