Screening Form

AUTHORIZATIONS : ***Please read the following sections thoroughly***

AUTHORIZATIONS : Please read the following sections thoroughly

I waive any right that I may have to inspect any information provided about me by any person or or organization identified by me in this screening form. I further understand that a response from a law enforcement agency from Oregon or any state indicating prior charges or convictions will mean that I may not be allowed to serve or be employed for any Church sponsored activity or program for preschool, children, or youth. These individuals may not serve in these areas. Should my application be accepted, I agree to be bound by the By-laws and Policies of Mannahouse.

i . I am stating that I have read and agree to above statement

ii.

I have read and agree to abide by the Policies for Prevention of Child Abuse and Risk Management presented with the Prevention of Child Abuse Policy

iii. By checking this box, I am stating that I have read and agree to the above statement

Legal First Name

Legal Last Name

Middle Name

Maiden Name

Street Address

City

State

Zip

Phone Number

Phone Carrier

Email Address

Gender

Birth Date

Social Security Number

Marital Status

Anniversary Date

Which campus do you attend?

Reason for screening

Name of person who asked you to complete this form

Email address of person who asked you to complete this form :

Ministry Center

Have you ever been arrested for, charged with, under probation for, or convicted of SEXUAL or PHYSICAL abuse?

Have you ever used illegal drugs?

Have you ever been convicted of a criminal offense?

Involving you or your background has there been a situation that would call into question being entrusted with the supervision, guidance, and care of people?

Has your Driver’s license ever been suspended or revoked?

Do you possess a current Driver's license?

Application for volunteer service with MANNAHOUSE CHURCH

a. In connection with my application for volunteer service with MANNAHOUSE CHURCH, I authorize MANNAHOUSE CHURCH, and/or ACTIVE SCREENING FAITH, their agent, to solicit background information relative to my criminal record history. I understand that MANNAHOUSE CHURCH, may conduct inquiries into my background that may include criminal records, personal references and other public record reports pertaining to me.

I am stating that I have read and agree to the above statement

b. I authorize without any reservation, any person, agency, or other entity contacted by MANNAHOUSE CHURCH, and/or ACTIVE SCREENING FAITH, their agent for purpose of obtaining background report information, to furnish the above mentioned information.

I am stating that I have read and agree to the above statement

c. I release MANNAHOUSE CHURCH, their respective employees, or ACTIVE SCREENING FAITH, their agent, and employees and all persons, agencies and entities providing information or reports about me from any and all liability arising out of furnishing any such information or reports.

I am stating that I have read and agree to the above statement

d. By typing your name and date below you are confirming that you are 18 years of age or older OR have the full permission of your guardian to be completing this form. You are also stating that you have answered al questions truthfully to the best of your knowledge.

i. Full Name (as signature)

ii. Today's Date

mm/dd/yyyy

Notes?

Send me a copy of my responses

Report Abuse