Application to Work with Children

Required of all clergy and paid staff without exception, and of all volunteers who work with children, youth, or vulnerable adults

Adopted · Dated 9 July 2026

This application is required by the Safe Church Policy as Step Two of the four safety steps. Complete every section, sign the statement at the end, and return the form to the Rector or their designee to be placed in your file. This application, and the corresponding background check, must be repeated every three years for lay workers; clergy follow the diocesan five-year cycle.

Applicant Information

Full legal name
Date of birth		Sex
Phone (home)		Phone (cell)
Email
Address
City		State & ZIP
Years at address		Years in state
Employer
Employer address
Emergency contact		Phone

Ministry Interest

In which program or programs do you want to become involved?

Experience with Children and Youth

What other children’s or youth work experience do you have? Include churches you have regularly attended over the past ten years.

Organization

Program

Dates

Contact

Education

Name of institution

Year

Degree

High school

College

Other

Screening Questions

Please answer each of the following. Explain any “Yes” answer on a separate page.

Yes	No
		Have you at any time been arrested for any reason?
		Have you at any time been convicted of, or pleaded guilty or no contest to, any crime?
		Have you, or any immediate family member or person living in your household, been convicted of, pleaded no contest to, had adjudication withheld for, or been placed under active arrest for, any crime involving abuse or neglect?
		Have you at any time engaged in, or been accused of, or pleaded guilty or no contest to, any child molestation, exploitation, abuse, or sexual misconduct?
		Are you aware of having any traits or tendencies that could pose any threat to children, youth, vulnerable adults, or others?
		Are you aware of any reason why you should not work with children, youth, vulnerable adults, or others?
		Have you regularly attended Christ Our Hope for at least six months? (Newly hired clergy are exempt from this requirement.)
		Are you willing to submit to a criminal background check before beginning your position?

References

Supervisor references

List your immediate supervisor, or an acceptable substitute, at each of your most recent places of employment.

Name		Organization
Position		Phone
Name		Organization
Position		Phone

Personal references

List at least two personal references who are not related to you.

Name
Relationship		Phone
Name
Relationship		Phone

Statement and Authorization

I recognize that Christ Our Hope Anglican Church is relying on the accuracy of the information I provided on the Application to Work with Children form. Accordingly, I attest and affirm that the information I have provided is true and correct.

I authorize the organization to contact any person or entity listed on the Application to Work with Children form, and I further authorize any such person or entity to provide the organization with information, opinions, and impressions relating to my background or qualifications.

I voluntarily release the organization and any such person or entity listed on the Application to Work with Children form from liability involving the communication or information relating to my background or qualifications.

I understand that a criminal background check is required before I may begin serving, and that I will complete a separate disclosure and authorization form provided by the background screening agency for that purpose.

I have carefully read the policies and procedures described in the Safe Church Policy, and I agree to abide by them and to protect the health and safety of the children, youth, and vulnerable adults assigned to my care or supervision.

Name printed
Signature		Date

Please read this document carefully before signing.