Safe Ministry Screening Questionnaire (Under 18)

For anyone aged under 18 serving as a volunteer or a junior volunteer/helper. This is a sensitive document that must be stored in a confidential manner accessible only by a limited number of authorised persons.

PERSONAL DETAILS

Your Name(Required)

Given Name Middle Surname

Previous Name/s (if applicable):

Given Name Middle Surname

Date of Birth(Required)

Sex(Required)

Male

Female

Phone/s(Required)

Your Address(Required)

Street Address Address Line 2 Suburb/Town/City Postcode

Your Email Address(Required)

Email Address Confirm Email Address

Do you have any health conditions that we should know about?(Required)

Name of at least one Parent/Guardian

First Last

Contact Phone for Parent/Guardian

Please circle either “YES” or “NO” for each of the following questions. If the answer to any of the following questions is “yes”, please give details on a separate page or discuss with the Senior Pastor or the person holding an equivalent leadership role in your church. A ‘yes’ answer will not automatically rule an applicant out of selection. Please note that, if you disclose any potentially criminal actions, the church may need to report this information to the police or other relevant government authorities.

1. Have you ever been charged with and/or convicted of a criminal offence?(Required)

Yes

2. Have you a history of alcohol abuse or a history of substance abuse including prescription, over-the-counter, recreational or illegal drugs? Yes / No (Required)

Yes

3. To your knowledge, has there ever been any allegations made against you regarding any abuse of a child, physical abuse or sexual misconduct?(Required)

Yes

CHURCHES YOU HAVE ATTENDED REGULARLY IN THE PAST 3 YEARS

List

Name of church

Location

When (Month/Year)

Any positions held

REFEREES

Please provide details of two referees who are over eighteen years of age and able to give a verbal report on your character and suitability for ministry. Referees may be part of the church.

Name(Required)

First Last

Phone Number(Required)

Name(Required)

First Last

Phone Number(Required)

CONSENT TO HOLD INFORMATION

I consent to the information contained in this application, including any subsequent pages, to be kept by our church. I understand that this information will be kept in a confidential file and used only for screening purposes.

DECLARATION

I sincerely declare that: • The information I have provided in this application is true and correct to the best of my knowledge and belief. • I understand that if I provide false or misleading information or withhold relevant information from this questionnaire, the church leadership may determine that I am unsuitable to serve in any role in the church. • I have received a copy of the Code of Conduct and am willing to uphold it.

Applicant’s Signature(Required)

Date(Required)

Name of parent/guardian

First Last

PARENT GUARDIAN SIGNATURE(Required)

Date(Required)

Name

This field is for validation purposes and should be left unchanged.