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16790 Van Wagoner St
Spring Lake, MI 49456
(616) 846-8556
 Service Times
Sundays 9 and 10:45am
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Home  //  Grow  //  Student Ministries Volunteer Disclosure Form
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* Required information.

Lakeshore Lutheran Fellowship Church cares about the children and youth in our ministry programs and desires to ensure their safety while they are in the church’s supervision.  Because of this, we are asking any new staff member or volunteer who will be ministering to children/youth to complete this disclosure form.  Please answer the following questions by circling the appropriate response.  Please include an explanation for any ‘yes’ answer(s).
Name *
Date of Birth * 1000
Address *
City *
State *
Zip *
Maiden Name
Other names you have used
Home Phone
Cell Phone
E-Mail

     
1. Have you ever been arrested, convicted, or pleaded guilty to a crime?
If yes, explain

   
2. Have you ever been accused, charged, alleged to have, or have you ever committed for an act of neglecting, abusing, or molesting any child?
If yes, explain

    
3. Have you ever been concerned that you may have an addiction to drugs, alcohol or pornography; or has anyone ever suggested that you may have a problem with any of the above?
If yes, explain

   
4. Have you been convicted of possession, use, or sale of drugs within the last 7 years?
If yes, explain

   
5. Have you been released from incarceration for a conviction of the possession, use, or sale of drugs within the last seven years?
If yes, explain

   
6. Within the last 30 days have you abused alcohol, legal, or illegal drugs?
If yes, explain

   
7. Have you ever been treated for a psychiatric disorder?
If yes, explain

   
8. Has your driver’s license been suspended or revoked within the last seven years?
If yes, explain

   
9. Is there any fact, circumstance, or pattern involving your background that would make it inappropriate for you to serve with minors or would compromise the integrity of the church?
If yes, explain

   
10. List (name, city, state) of other churches you have regularly attended during the past three years:

   
11. List all previous church work involving children:

   
12. List all previous non-church work involving children (organization name, city, state, type of work):

   
13. I feel that my strength(s) when working with children/youth are:

 

I am committing to leading Children’s Ministry Leader B.A.M. or 2.52 class for one school year (September – May).   If, at any time, I will not be able to keep this commitment, I will give/be given proper notice to/from one of the leaders of Lakeshore Lutheran Fellowship.

You have my permission to obtain a police check of my personal record.  In addition, I authorize any references or churches listed in this application to give you any information (including opinions) that they have regarding my character and fitness for ministry.

I agree to live by the understanding that, as a person in authority, it is my responsibility to avoid sexual contact with children and/or youth, even if one attempts to initiate the contact.

I will find alternative ways to discipline, agreeing that under no circumstance will I use spanking, neck or choke holds, ear or hair pulling, or any other corporal punishment as a means of discipline.

I certify that the information I have provided is true and correct.  If it is found that the answers given are untrue, I understand it may be a cause for dismissal.
*** I agree to all the conditions above *

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