LRBC Child Protection/Safety Application Form A
Little River Baptist Church seeks to provide a safe environment for all our children, youth and vulnerable adults. To that extent, we request that you complete the following information so that we are able to verify information, check references, and perform needed background checks.
Name:
Your answer
Address:
Your answer
Contact phone number:
Your answer
email address:
Your answer
Date of Birth
MM/DD/YYYY
Your answer
Driver's License Number: (required for background check)
Your answer
SSN: (required for background check)
Your answer
Marital Status
Are you a member or regular attendee of this church?
If so, for about how many years?
Your answer
How long have you lived at your current address?
Your answer
Previous address:
Your answer
List all cities and states where you have lived as an adult
Your answer
Please list the name, address, city and state of other churches you have attended regularly during the past 10 years:
Your answer
Please list all previous church work involving children, students or vulnerable populations (impaired, adults, special needs individuals etc.). (List each church’s name and address, type of work carried out, dates, and a contact person familiar with your work there.
Your answer
Please list all previous non-church work involving children, students or vulnerable populations. (List each organization’s name and address, type of work carried out, dates and a contact person familiar with your work there.
Your answer
List any talents, vocations, preparation, training or other experiences which have equipped you to work with children, students or vulnerable adults:
Your answer
Release:
I authorize LRBC to contact individuals and references listed on this Safety Application to verify the information provided by me. I agree to release from liability any person or organization that provides info concerning me, including those persons I have listed as references as well as contact persons from my previous church and non-church work, listed here. I specifically authorize the church o undertake a criminal background check concerning my past. I understand and agree than any information received from the background check and application verification will not be disclosed to me, and I hereby waive any right to inspect the info provided those persons or organizations I have identified on this form. By placing my initials in the blank below on this form, I certify and affirm that the info I have given on this form is true, complete and correct in all respects.
Your answer
Date of completion:
MM
/
DD
/
YYYY
Submit
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