Children/Youth Application Form

The following documents, in addition to completing the form below, must be completed and signed at or before your interview:

Applicant’s statement

Authorization for Background Check

Subject: *
E-mail Address: *
First Name *
Middle Name
Last Name *
Date
Present address *
City *
State *
Zip code *
Home phone number
Other phone number
How long have you been a Christian?
Give a brief testimony of how you became a Christian.
Are you a member of Harvest Time Bible Church? *	yes no
How long?
List the names of other churches you have attended regularly during the past 5 years
List all previous church work you have done involving children or youth. (list church name, address/phone number, type of work and dates)
List all previous non-church related work you have done involving children or youth. (list organization name, address/phone number, type of work performed, dates)
List any gifts, calling, training, education or other factors that you feel have prepared you for work with children/youth.
Which type of ministry work do you prefer, children or youth?	children youth
What age?	preschool elementary middle school high school
Have you ever been formally charged, arrested or convicted of or plead guilty to a crime involving child abuse or child molestation, physical abuse of any kind, alcohol or illegal drug use, possession, sale or related offense? *	yes no
If yes, explain.
Have you ever been a complainant or a subject of the Illinois Department of Children and Family Services (DCFS) investigation? *	yes no
If so, what was the nature of the complaint?
What was the outcome?
Explain
Were you a victim of abuse or molestation as a minor? (If you prefer, you may refuse to answer this question. Answering yes, or leaving the question unanswered will not automatically disqualify you as an applicant for youth or childrens work.)	yes no prefer not to answer
Do you have a current drivers license? *	yes no
If yes, has your drivers license ever been suspended or revoked? *	yes no
If so, for what reason?
Explain.
Drivers License Number
Type of license.	passenger CDL air breaks school bus
Would you be willing to drive a bus or van for children/youth events?	yes no perhaps in future but not now
Personal reference#1 as to your character (not former employees or relatives) – list name, address, phone number and relationship
Personal reference#2 as to your character (not former employees or relatives) – list name, address, phone number and relationship


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