background check form Question Title * 1. Please fill in the below information: First Name: * Middle Name: * Last Name: Address: * City: * State: ZIP: Previous Names (including Maiden name): Email Address: Phone Number: Please fill out each item below to be considered for volunteering at Redeemer United Methodist Church. Question Title * 2. County of Residence Question Title * 3. What ministry area are you volunteering for? Question Title * 4. Birth Date: Question Title * 5. Race/Ethnicity: Question Title * 6. Gender: Male Female Question Title * 7. Social Security Number (No SS# will be stored on paper or computer at Redeemer UMC) Question Title * 8. Have you been convicted of, or pleaded guilty to, or are charges pending concerning any criminal offense? Yes No If yes, please explain. Question Title * 9. Have you ever abused a minor or engaged in any conduct that could be regarded as child abuse, child sexual abuse, or neglect? Yes No If yes, please explain. Question Title * 10. In addition to the above, is there any fact or circumstances involving you or your background that would call into question your being entrusted with the care and supervision of children or youth? Yes No If yes, please explain. Question Title * 11. I hereby give consent to Redeemer Church to conduct a background check on me, as I am seeking to be a volunteer working with children, disabled or vulnerable adults, elderly persons, or financial matters. I authorize references listed to give you any information (including opinions) that they may have regarding my character and fitness for ministry with children or youth. I hereby release and agree to hold harmless from liability any person or organization that provides information, and I waive any right to inspect any information provided about me. I also agree to hold harmless Redeemer Church, and its paid staff members and volunteers. I authorize the release of any information which pertains to any record of convictions contained in law enforcement files or in any criminal file maintained on me whether it be local, state, or national. I hereby release local, state, and national law enforcement agencies from any and all liability resulting from such disclosure. I agree to the above. By checking this box, I am electronically authorizing my signature. Done