UUFSD RE Volunteer Application

Thank you for your interest in working with the children and youth of our congregation. Our congregation takes seriously our responsibility of assuring the safety of our youth.

Thank you for your support in providing a safe and secure environment for all of the congregation's children and youth.

Name

This address will receive a confirmation email

Have you ever used a different name?

Yes No

If yes, please list with dates:

How long have you attended this congregation?

Are you a member?

Yes No

Address

Number of years at this address?

If you have not lived at this address for at least 5 years, list any previous addresses with dates covering the past 10 years

What states have you lived in since you were 18 years old?

Home Phone

Work Phone

Background Check Federal and state law, along with our Child and Youth Protection policy, requires us to perform a criminal background check screening on all candidates looking to work with children and youth. Are you willing to take a background check? PLEASE NOTE: You will not be eligible to perform classroom duties until your background check screening is finalized. Regular Volunteers (exceeding 16 hours/month or 32 hours/year) will also be required to undergo fingerprinting through LiveScan.

Yes No

Have you ever been convicted of any criminal offense?

Yes No

If yes, please explain.

Have you ever been accused of any crimes against a person, including rape, incest, sexual exploitation of a minor, or sexual or physical assault of a minor?

Yes No

If yes, please provide details

Other than the above, is there any fact or circumstance involving you or your background that would call into question your being entrusted with the supervision, guidance, and care of children and youth?

Yes No

If yes, please provide details

Congregation History and Prior Work with Children and Youth:

List congregations you have attended during the past five years. Please include the following information for congregation other than the Unitarian Universalist Fellowship of San Dieguito: Name of congregation; City; State; and dates attended.

List all previous work involving children and youth (list name, type of work performed, person you were responsible to)

Please list the groups and organizations you have been involved with in this congregation. Place an asterisk by those you are currently active in.

Please list two references who are not relatives who have known you for at least three years and who are familiar with your character as it pertains to your experience with children or youth. Include their name, phone, address, and relationship to you.

I authorize the congregation to contact references and other congregations to obtain information about my background regarding my character and fitness for work with children and youth. I authorize references to provide such information about me. I hereby release and hold harmless from liability any person or organization that provides information. I also agree to hold harmless this congregation, its trustees, employees and volunteers.

Further, I understand that a member of the staff may check the sex offender registry and/or contact the local police for more information about my background. This information will be available only to those responsible for screening staff or volunteers or participating in a response team, or as required by law.

I attest that the above information is true and correct.

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Date

UUFSD RE Volunteer Application

Description

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