Safe Sanctuary Application • First United Methodist Church

First Name *

Last Name *

Home Address *

Home City *

Home State *

Home Zip Code *

Email Address *

Phone Number

Mobile Number

Date of Birth *

Membership Status

Regular Attender

Member

Other

Do you currently work/serve at FUMC?

Yes

Are you certified in CPR?

Yes

Are you certified in First Aid?

Yes

Do you have a current valid Driver's License?

Yes

Are you a Jr or High School Student?

Yes

If yes, who is your parent or guardian?

What is your parent/guardian phone number?

Please tell us about your previous experience.

Occupation

Tip: Your past occupation if retired.

Please tell us when you have availabliity.

Tip: Check all that apply

What is your T-Shirt size?

Affirmation

For the protection of church family, FUMC requests a response to the following items:

1. I understand that I must agree to read the Safe Sanctuary Policy and follow it's guidelines. *

Yes

2. I understand it is the church policy to offer the opportunity to participate in programs, services and activities without regard to race, color, religion, sex, age, ethnic origin national origin, political belief or family background. *

Yes

3. I am aware that First United Methodist Church of Mountain Home conducts background checks for those working with children, youth and impaired adults. I hereby approve of such a check on my background. I agree to provide the necessary information requested. *

Yes

4. During your lifetime, have you ever been arrested for molesting or abusing a child, accused of physical assault or a sexual offense of any nature? *

Yes

If yes, please explain:

References

Please list three (3) personal references (not related to you):

Ref #1 Name *

Ref #2 Name *

Ref #3 Name *

Ref #1 Phone Number *

Ref #2 Phone Number *

Ref #3 Phone Number *

Electronic Signature

Your typed name here acts as your signature and confirmation that all information in this form is true to the best of your knowledge.

Your Full Name *

Today's Date *