Become a Mentor

Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Have you ever volunteered with a tutoring center? *

yes

no

Have you ever been convicted of a criminal offense? *

If yes, please explain.

Yes

No

Have you ever engaged in or been accused or convicted of child abuse, indecency with a child, or injury to a child? *

If yes, please explain

Yes

No

Have you been treated for any nervous or mental illness? *

If yes, please explain

Yes

No

Have you ever gone through any treatment for drug or alcohol abuse? *

If yes, please explain

Yes

No

Do you have any special health considerations that we should know about? *

If yes, please explain.

Yes

No

Would you like to meet with The Learning Zone Director regarding any of these issues? *

Yes

No

YOUR NAME *

First Name

Last Name

APPLICANTS STATEMENT *

I recognize that the Vineyard Christian Fellowship - Westside to which this application is being submitted is relying on the information contained herein. Accordingly, I attest and affirm that all of the information that I have provided in this application is absolutely true and correct. I authorize any references or churches listed in this application to give you any information (including opinions and impressions) that they may have regarding my character and fitness for children’s ministry. I release all such references from any liability for furnishing such evaluations to you, provided they do so in good faith and without malice. I waive any right that I may have to inspect references provided on my behalf. I authorize the Vineyard Christian Fellowship - Westside to conduct a criminal background and/or driving history check if such a check is deemed necessary. Should my application be accepted, I agree be bound by the bylaws and policies of the Vineyard Christian Fellowship - Westside; refrain from unscriptural conduct in the performance of my services on behalf of the church; and protect the health and safety of children at all times.

Yes

No