KIDS COUNT MENTOR APPLICATION

Your name *

Last name

Email address *

Phone number *

Phone type

Which is the best method to contact you?

Text

Phone

Address *

Country

Street Address

Apt/unit/box (optional)

City

State

Postal code

Birthdate *

Marital Status

How long have you attended North Mar Church? *

Do you regularly attend two or more services each month? *

Yes

In a brief paragraph, please outline your spiritual journey, including when you received Jesus as Savior. *

QUALIFICATION AND AVAILIBILITY OF SERVICE

Why do you want to serve as a mentor? Include description of any previous experience working with children, youth, or disabled individuals. *

Are you currently employed? If so, who's your current employer? *

Have you taken any courses or received any training that would equip you for mentoring? If so, please list. *

Describe any condition, preference, or belief that might restrict or prevent you from performing certain activities involved in the volunteer position for which you are being considered. *

Example: handling emergency, driving, participating in certain sports, extended vacations.

Please indicate days/times you are available to mentor. *

Monday morning

Monday lunch

Monday afternoon

Tuesday morning

Tuesday lunch

Tuesday afternoon

Wednesday morning

Wednesday lunch

Wednesday afternoon

Thursday morning

Thursday lunch

Thursday afternoon

Friday morning

Friday lunch

Friday afternoon

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.

Do you possess any traits or tendencies that could pose a threat to others? If yes, please explain the trait or tendency? *

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 last nine 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

Name *

Address *

Country

Street Address

Apt/unit/box (optional)

City

State

Postal code

Phone number *

Phone type

Name *

Address *

Country

Street Address

Apt/unit/box (optional)

City

State

Postal code

Phone number *

Phone type

Name *

Address *

Country

Street Address

Apt/unit/box (optional)

City

State

Postal code

Phone number *

Phone type

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.

In consideration of the receipt and evaluation of this application form by North Mar Church, I hereby release the Church and their employees, representatives, and any other person or organization, including record custodians, that may release information concerning me, both collectively and individually, from any and all liability for damages of whatever kind or nature which may at any time result to me, my heirs or family on account of inquiries concerning my background an any disclosures of information concerning me to North Mar Church. I waive any right that I may have to inspect any information provided about me by any person or organization identified by me in this application.

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 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 a member of the pastor staff, or an elder.

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