BACKGROUND CHECK

BACKGROUND CHECK

For the safety of our youth and children we want to ensure that our volunteers are thoroughly vetted. Authenticity and honesty are essential to the Christian witness so please carefully answer the following questions. Any special concerns or issues can be discussed privately with one of Waipuna Chapel’s Pastors. All information will be kept strictly confidential.

May Waipuna Chapel have permission to run a background check on you? Yes No If no, please explain. ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ If yes, please provide the following information: First and Last Name: _______________________________________________________________________________ Date of Birth _________________________________ Place of Birth: ________________________________________ SS#: ________________________________________ Home Address (Street | City | State | Zip Code) : ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ Phone #: _____________________________________________________ E-Mail: ______________________________________________________



To the best of my knowledge, the information contained in this application is correct. I, the undersigned, give my authorization to Waipuna Chapel or its representatives to release any and all records or information relating to working with minors. Waipuna Chapel may contact my references and appropriate government agencies as deemed necessary in order to verify my suitability as a ministry volunteer. I understand that the personal information in this application is confidential and will be treated as such.

Signature ______________________________________________ (Volunteer) Signature ______________________________________________ (Ministry Head)

Date __________________________ Date __________________________