Child Protection Certification Application Form

Your name *

Email address *

Personal Information

Legal first and last name *

If you are filling this out for a child, please put their name here

Maiden name (if applicable):

Race *

American Indian or Alaskan Native

Asian or Pacific Islander

Black

Unknown/Other

White

Phone Number *

Address *

Primary Campus *

Middleville

Wayland

How long have you been attending Peace Church? *

Do you hold membership at Peace Church? *

Yes

Have you ever been convicted of, plead guilty or no contest to a crime other than a minor traffic violation? *

Yes

If yes, please explain:

Are you currently being faced with any charges for a criminal offense? *

Yes

If yes, please explain:

Driver's License Number

This information is required if you hold a driver's license. This does not apply if you don't have one or if you are a minor.

Do you have any restrictions on your license?

Yes

If yes, please explain:

Have you been involved in any motor vehicle accidents in the last five years? *

Yes

If yes, please explain:

Have you been cited for any moving violations in the last five years?

Yes

If yes, please explain:

Do you carry liability insurance on your vehicle?

Yes

No (Please note: Volunteers that do not carry liability insurance are not allowed to drive minors.)

If yes, please identify your insurance company:

References

Please list at least two references from places of employment or prior volunteer service, especially regarding previous work with children and youth. References should be able to speak to your ability to work with young people. ADULT APPLICANTS-References need to be at least 18 years of age, not a relative and must have known you at least a year.

Reference #1 First & Last Name *

Reference #1 Relationship to You *

ADULT APPLICANTS-References need to be at least 18 years of age, not a relative and must have known you at least a year.

Reference #1 Email *

Reference #1 Phone Number *

Reference #1 Length of Time Known *

Reference #2 First & Last Name *

Reference #2 Relationship to You *

ADULT APPLICANTS-References need to be at least 18 years of age, not a relative and must have known you at least a year.

Reference #2 Length of Time Known *

Reference #2 Email *

Reference #2 Phone Number *

Policy Questions

The following questions review our Child Protection Policy. Questions must be answered correctly in order to be approved.

The policy can be found at peacechurch.cc/childprotectionpolicy

Who is allowed to assist children in restrooms or with diapering, and what specific procedures must be followed to maintain appropriate visibility and accountability? *

What is the minimum number of adults in a classroom with kids/students? Can they be from the same household? *

Which applicants must undergo a background check? *

List the two types of discipline that are never allowed to be used with children and youth? *

If a volunteer suspects abuse or neglect, what are the required steps and timeline for reporting, both internally to Peace Church staff and to CPS (if mandated)? *

By typing your name below, you agree to abide by the current Peace Church Child Protection Policy.

Personal Information

Personal Background

References

Policy Questions