Madison Christian Community Parish Protection Program Application Form
Note: All information on this application will be kept confidential.

You MUST be over 18 to fill out this form electronically. Minors must use the paper version accompanied by a parent signature found at http://madisonchristiancommunity.org/parish_protection_program.aspx.

Last Name *
Your answer
First Name *
Your answer
Middle Name *
Your answer
Street Address *
Your answer
City, State Zip *
Your answer
Phone Number *
Your answer
Email address *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
List programs and activities (both within the congregation and the community) where you have worked with young people. *
Your answer
If you do not have experience working with children, please explain why you are now interested.
Your answer
References:
Please provide the names, addresses, phone numbers, and emails of three references who are not related to you. One may be from the MCC, two must be from outside. These references should be able to describe you in a way that is relevant to your involvement in child and youth ministries. All references will be sent an evaluation form to complete.
1. Name, Address, Phone Number, Email *
Your answer
2. Name, Address, Phone Number, Email *
Your answer
3. Name, Address, Phone Number, Email *
Your answer
Background Check Information
1. Is there any circumstance in your background which would call into question your being entrusted with the supervision, care or guidance of children or youth? If yes, please explain. *
Your answer
2. Have you ever been convicted of a crime? If yes, please explain. (This is only given consideration if the offenses substantially relate to the job.) *
Your answer
3. Do you have any pending charges or convictions? If yes, please explain. (This is only given consideration if the charges substantially relate to the job.) *
Your answer
4. Have you ever been accused of sexual misconduct or abuse? If yes, please explain. By whom were you accused? Was there any court or social service involvement? *
Your answer
5. Do you currently use illegal drugs? If yes, please explain. *
Your answer
Code of Ethics Statement
All the information I have provided in the process of applying to work with the children and/or youth of The Madison Christian Community is true and correct to the best of my knowledge. I voluntarily and knowingly authorize any person named herein as a reference to give to the staff of the Madison Christian Community any information they may have regarding my character and fitness for working with children and youth. I voluntarily and knowingly fully release and discharge all such references from liability for any evaluation provided of me. I consent to having a State of Wisconsin Department of Justice records check. By typing my name below, I am signing this application electronically. I agree my electronic signature is the legal equivalent of my manual signature.
Electronic Signature *
Your answer
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