Volunteer Application

Personal

Your Name*
Other Names Used (Maiden, Former Married Names)
Date of Birth
Driver’s License #
SSN
Email Address*
Present Address
City
State
Zip
Phone

Residence History

How long have you lived in Texas
State
Length of Residence
State
Length of Residence

Previous Work Involving Students, Volunteer or Paid

Organization
time
Type of Work
Supervisor’s Name
Phone
Office Use
Organization
Time
Type of Work
Supervisor’s Name
Phone
Office Use

Personal References

Name
Nature of association
Phone
Office Use
Name
Nature of association
Phone
Office Use

Personal History

Are you an adult survivor of child abuse? Yes   No   
If Yes, please explain
Is there anything in your personal history that would prevent you from serving children/youth? Yes   No   
If Yes, please explain

Criminal History

Have you ever been arrested for, charged with, indicted for, convicted of, or entered any plea of guilty or no contest to any offense involving a minor? Yes   No   
If Yes, please explain
Have you ever been arrested for, charged with, indicted for, convicted of, or entered any plea of guilty or no contest to any offense involving a violent act against another person? Yes   No   
If Yes, please explain
Have there ever been allegations of abuse or neglect made against you? Yes   No   
If Yes, please explain
Have you ever been investigated by Child Protective Services (or any similar agency from another state) for abuse or neglect? Yes   No   
If Yes, please explain
Have you ever been terminated from employment due to allegations of abuse or neglect? Yes   No   
If Yes, please explain

I authorize Kingdom Life Academy to make criminal record checks. I understand all information is considered strictly confidential. I further understand that the falsification of any answer on this questionnaire could result in the loss of my privilege of working with the students at Kingdom Life Academy. I further agree that subsequent background checks can be made if deemed necessary.

Applicant Signature
Date
Office Use
Criminal Record Check