2017-18 Screening Form

* indicates a required answer.

CONFIDENTIAL                                             CONFIDENTIAL

 

SHINE--Supporting Homeschoolers in the NorthEast

Initial Screening Form for Work with Children/Youth

2017-2018

 

 This application is to be completed by all adults and teens wanting to serve in any position involving the supervision or custody of minors. This form will be used to help the SHINE Homeschool Group provide a safe and secure environment for those children and youth who participate in our programs.

All information given in this Screening Form is Confidential. We ask that you please be honest in answering all questions. Lack of disclosure will result in immediate denial or termination of membership without refund of membership fees. 

1.*

Please indicate your reason for filling out the Screening Form. You may choose one or more if they apply.:

 (1 required)
New Member Parent Co-op Teacher
Guest Speaker/Teacher Visiting Friend or Relative
Renewing Member Parent

Personal

2. *

Date: 

3. *

Full Name (Last, First, Middle): 

4. *

Cell Phone:

5. *

Home Phone:

6. *

Current Address:

Identity must be confirmed listing a driver’s license or other photographic identification number below.

7. *

Please enter your driver's license state and number. If you don't have a current driver's license, please enter a state or military ID number/information.

8. *

Have you ever been convicted of or pleaded guilty to a crime?

Please type YES or NO. If YES, please explain in detail what the situation was.

9. *

Have you ever used/experimented with illegal drugs as an adult?

Please type YES or NO. If YES, please explain in detail.

10. *
Have you been a victim of abuse or molestation at any time in your life?
(Our insurance requires we ask this question because it is industry standard for anyone working with children.)

Please type YES or NO. If YES, please explain situation.

11. *

Do you have any health problems (physical, mental, emotional) and/or are you under a physician’s care for any reason?

Please type YES or NO. If YES, please explain in detail.

12. *

Do you have any Red Cross/emergency/first aid training?

Please type YES or NO. If YES, please enter course name and date taken.

 

Homeschool Group/Church History and Prior Work with Children/Youth

13. *

Name of church of which you are a member or regular attender: 

14. *

Pastor's Name:

15. *

Church phone number: 

16. *

List all previous homeschool group, church work, school work, or volunteer work involving children or youth (list each group/church’s name, address, type of work performed, dates): 

 

Personal References (not former employees or relatives):

17. *

Reference #1 - Full Name:

18. *

Reference #1 - Address:

19. *

Reference #1 - Home Phone/CellPhone:

20. *

Reference #2 - Full Name:

21. *

Reference #2 - Address:

22. *

Reference #2 - Home Phone/Cell Phone:

 

APPLICANT’S TESTIMONY 

 

 Our mission is to provide opportunities for encouraging homeschool families in the endeavor of faithful Christian training and education of their children in the Northeast San Antonio area.  Our theme verse, Matthew 5:16, “Let your light so shine before men, that they may see your good works and glorify your Father in heaven,” exemplifies our desire to honor Christ in all that we do.

 Because we are Christian Homeschooling group, we desire to know where our members stand in their walk with Christ. This information is confidential and will help us to best place you for service within our group. We appreciate you taking the time to fill this out.

23. *

Applicant's Name:

24. *

Have you accepted Jesus Christ to be your Savior?

Please type YES or NO below. If YES, please answer the remaining questions. If NO, please type N/A into the other boxes.

In 1 Peter 3:15, the Apostle Paul charges believers to "Always be prepared to give an answer to everyone who asks you to give the reason for the hope that you have." Please write out below a brief testimony of your conversion--how you know you have eternal life. Then please share a little of how you have grown spiritually since becoming a Christian.

25. *

1. How I accepted Jesus Christ as my Savior:

26. *

2.  How I have grown in my Christian walk:

Applicant’s Statement

 

The information contained in this application is correct to the best of my knowledge. I authorize any references or churches listed in this application to give SHINE -- Supporting Homeschoolers in the NorthEast any information (including opinions) that they may have regarding my character and fitness for children’s or youth work. I understand that this information may be used to conduct a criminal background check as a part of the screening process. In consideration of the receipt and evaluation of this application by the SHINE Steering Committee, I hereby release any individual, church, youth organization, charity, employer, reference or any other person or organization, including record custodians, both collectively and individually, from any and all liability for damages of whatever kind or nature which may at any time result to me, my heirs, or family, on account of compliance or any attempts to comply with this authorization. 

 

Should my application be accepted, I agree to be bound by the Policies and Procedures of SHINE--Supporting Homeschoolers in the NorthEast and to refrain from unscriptural conduct in the performance of my services on behalf of the SHINE Homeschool Group.

 

I further state that I HAVE CAREFULLY READ THE FOREGOING RELEASE AND KNOW THE CONTENTS THEREOF AND I SIGN THIS RELEASE AS MY OWN FREE ACT. This is a legally binding agreement, which I have read and understand.

27. *

Applicant's Signature and Date:

Please type your full name and today's date below. **By typing your name below, you certify that it acts as your legally binding signature in agreement with this application.**

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