Student Ministry Volunteers

1

Full Legal Name

First Name

Last Name

2

Other Names Used

First Name

Last Name

3

Phone Number

Area Code

Phone Number

4

Date of Birth

Date

Month

Day

Year

5

E-mail

6

Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

7

Emergency Contact Name

First Name

Last Name

8

Emergency Contact Phone Number

Area Code

Phone Number

10

Do you use illegal drugs?

YESNO

11

Have you ever been convicted of a criminal offense?

YESNO

12

If yes, provide the date convicted

13

Have you ever been charged with neglect, abuse, or assault?

YESNO

14

If yes, provide the date charged

15

Have you lived outside the State of Oregon anytime during the last 3 years?

YESNO

16

If yes, provide the place

17

If you answered "yes" to any of the above questions, please provide an explanation for each below.

18

Non-Family Reference #1

First Name

Last Name

19

Relationship to You

20

Phone Number

Area Code

Phone Number

21

Non-Family Reference #2

First Name

Last Name

22

Relationship to You

23

Phone Number

Area Code

Phone Number

24

Applicant Signature

First Name

Last Name

25

Date of Applicant Signature

Date