BUDDY BREAK NEW VOLUNTEER FORM

We recognize that this form is extensive but ask for your help in completing the form in its entirety. Your cooperation will assist church leaders in their efforts to provide a secure environment for developmentally disabled persons who participate in our programs and use our facilities. Your responses will be maintained confidential by North Mar Church Leadership.

Your name *

Last name

Email address *

Phone number *

Phone type

Can we text you? *

Yes

Address *

Country

Street address

Apt/unit/box (optional)

City

State

Postal code

Birthdate *

Marital Status

What is the name of the local church you attend?

Do you regularly attend two or more services each month?

Yes

In a brief paragraph, please outline your spiritual journey, including when you received Christ as Savior, your walk with the Lord, and your strengths and weaknesses. *

Areas of Interest (Check all that apply)

Being a Buddy (partner directly with the VIPs)

Nurse

Storyteller

Music Leader

Office/Administrative help (phone calls, emails, data entry, etc.)

Welcome/Registration

Set Up/Clean Up

Prayer Partners in Hospitality Room

Craft Helper

Craft Leader

Game Leader

Game Helper

Hospitality Room (for caregivers of VIPs)

Video Room Monitor (VIP station where video plays)

Other Area of Interest:

If you chose to be a Buddy, please provide your preferred age group. Keep in mind that this is not a guarantee that you can be placed with that group, though it does help with placement.

2 yrs -6 yrs

7 yrs - 10 yrs

11 yrs - 14 yrs

15 yrs - 18 yrs

No preference

QUALIFICATION AND AVAILIBILITY OF SERVICE

Our VIPs are all beautifully different. Some are on the go the whole time, some prefer to play one on one. Some are very vocal and loud, some barely speak. Most are somewhere in between.

Is there anything that might restrict you from performing certain activities involved in the volunteer position/s you chose? If yes, please explain.

Why do you desire to work in this ministry? Include description of any previous experience working with children, youth, or special needs individuals. *

Have you taken any courses or received any training that would equip you for working with children with special needs? If yes, please list. *

Have you ever been convicted of or plead guilty or no contest to any criminal offense of any kind (felony or misdemeanor, except for minor traffic violations)? *

You will need to answer “Yes” if you have entered into a plea agreement, including a deferred sentence or deferred judgment arrangement, in connection with a criminal charge.

Yes

If you have been convicted of or pled guilty or no contest to any criminal offense, please submit an explanation, including nature of offense, date, court where conviction was entered, and any other relevant information. *

Have you ever been arrested for, participated in, been accused of, pled guilty/no contest to, or been convicted of abuse or any sexual misconduct, or offense relating to children, or other crime of violence (that is not covered in the preceding question)? *

If you have been arrested for, participated in, been accused of, pled guilty/no contest to, or been convicted for such an offense, please submit a statement or explanation.

Include nature of offense charged, date, law enforcement agency making the charge, and any other relevant information.

Have you ever been reported to a social services agency, law enforcement authority, child abuse registry, or similar organization regarding abuse or misconduct involving children? *

Yes

Have you ever been subjected to expulsion, reprimand, or other discipline by a church, denomination, or other religious organization? *

Yes

Have you ever been the subject of a civil lawsuit involving sexual misconduct, sexual harassment, or other immoral behavior or conduct, involving adults or children? *

Yes

Have you ever been the subject of a complaint or disciplinary proceeding against a professional license or other license held by you, including but not limited to a license to provide childcare or similar services? *

Yes

Have you ever been the subject of any disciplinary action, transfer, or dismissal, or been named as a defendant in a civil or criminal lawsuit, as a result of an accident or mishap involving children? *

Yes

Have you ever been subject to any disciplinary action (including discharge) or investigation by a church, religious, or other organization, or by an employer? *

Yes

If your answer to any of the eight questions is “Yes,” for each positive response, please provide the following information: *

(1) date and complete description of the circumstances; (2) name and address of the church, employer, or other organization involved, and (3) name and telephone number of a person familiar with the circumstances.

*If there are any changes in the above provided information, the Outreach Pastor or Children's Ministry Director must be notified immediately.*

PERSONAL REFERENCES

References must be a non-relative adult.

Name *

Phone number *

Phone type

Name *

Phone number *

Phone type

Name *

Phone number *

Phone type

Email *

SIGNATURE REQUIRED *

The responses I have provided in completing this application form are complete, truthful, and accurate. I hereby authorize North Mar Church to make inquiries concerning my background in connection with evaluating the information I have provided on this form and in the application process, including a criminal records check. I hereby authorize all persons associated with me, including churches, employers, law enforcement, licensing and social services agencies, to release any information contained in their files or records concerning me to North Mar Church and its representatives.

I have carefully read the foregoing release and know the contents of it, and I sign this release as my own free and voluntary act.

I understand that my service with North Mar Church shall be volunteer service. In addition, my volunteer services shall be at-will and the church shall be entitled to terminate my services at any time, with or without cause or advance notice. I understand and agree that I am not an employee of North Mar Church, and that I have no expectation of future employment. As a volunteer, I have no entitlement to or expectation of compensation, health insurance, or other employee benefits, or unemployment or worker’s compensation insurance benefits.

I affirm that I will strictly comply with all policies and procedures of North Mar Church including but no limited to it Child Protection Policy as presented in the publication Safe Place. If at any time I find that for any reason I am unable to support the policies, procedures, or doctrine of North Mar Church, I will resign my volunteer position. I understand and agree that failure by me to abide by such policies and procedures may result in my immediate dismissal or disciplinary action, all in the discretion of North Mar Church. I will report any known or suspected child abuse or other violation of policy to the Outreach Pastor or Children’s Ministry Director, the Elder Board, or the Executive Pastor.

North Mar Church
info@northmarchurch.com
330-856-3496