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PLEASE FILL OUT THE FOLLOWING FORM TO BEGIN - THIS FORM IS SECURE AND CONFIDENTIAL TO OUR MINISTRY LEADERS.

Name *
Name
Date of Birth *
Date of Birth
Address *
Address
WHAT AREAS OF MINISTRY INTEREST YOU? PLEASE CHOOSE ONE:
CAMPUS SAFETY
CONNECTION
CHILDREN
STUDENTS
The purpose of the following questions is to assist in the creation of a safe environment for those who participate in the ministries of Waterstone Church.
HAVE YOU EVER BEEN CONVICTED OF ANY CRIMINAL ACTIVITY? *
HAVE YOU EVER BEEN CAUTIONED BY THE POLICE OR BOUND OVER TO KEEP THE PEACE? *
HAVE YOU EVER BEEN FOUND GUILTY BY A COURT EXERCISING CIVIL JURISDICTION (INCLUDING MARRIAGE/FAMILY JURISDICTION) TO HAVE CAUSED SIGNIFICANT HARM TO A CHILD OR YOUNG PERSON UNDER THE AGE OF 18 YRS., OR HAS ANY SUCH COURT MADE ANY ORDER AGAINST YOU ON THE BASIS OF FINDING OR ALLEGATION THAT ANY CHILD OR YOUNG PERSON WAS AT RISK OF ANY SIGNIFICANT HARM FROM YOU? *
HAS YOUR CONDUCT EVER CAUSED OR BEEN LIKELY TO HAVE CAUSED SIGNIFICANT HARM TO A CHILD OR YOUNG PERSON UNDER THE AGE OF 18, OR PUT A CHILD OR YOUNG PERSON AT RISK OF SIGNIFICANT HARM, OR TO YOUR KNOWLEDGE HAS IT EVER BEEN ALLEGED THAT YOUR CONDUCT HAS RESULTED IN ANY OF THOSE THINGS? (THIS QUESTION RELATES TO ANY CONDUCT, WHETHER IN A PAID, VOLUNTARY OR OTHER CAPACITY.) *
HAS A CHILD IN YOUR CARE OR FOR WHOM YOU HAVE OR HAD PARENTAL RESPONSIBILITY EVER BEEN REMOVED FROM YOUR CARE BY A GOVERNMENT AGENCY OR LEGAL PROCESS? *
DO YOU HAVE ANY HEALTH PROBLEMS WHICH MIGHT AFFECT YOUR WORK WITH CHILDREN OR YOUNG PEOPLE UNDER THE AGE OF 18? *
HAVE YOU, SINCE THE AGE OF 18, EVER BEEN KNOWN BY ANY OTHER NAME THAN THE ONE GIVEN ABOVE? *
HAVE YOU EVER RECEIVED PROBATION OR COMMUNITY SUPERVISION FOR ANY FEDERAL, STATE OR MUNICIPAL OFFENSE? *
HAVE YOU EVER BEEN CONVICTED OF ANY CRIMINAL OFFENSE IN A COUNTRY OUTSIDE OF THE JURISDICTION OF THE UNITED STATES? *
AS OF THIS DATE, DO YOU HAVE ANY PENDING CHARGES AGAINST YOU? *
HAVE YOU, DURING THE PAST FIVE YEARS, HAD ANY HOME ADDRESS OTHER THAN THAT GIVEN ABOVE? *
WHICH CAMPUS DO YOU ATTEND? *
ARE YOU A MEMBER OF WATERSTONE CHURCH? *
Have you completed the Stepping Stones classes?

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