LIFEPOINT CHURCH BACKGROUND CHECK APPLICATION
PERSONAL & CONTACT INFORMATION
This application is to be completed in full for any position involving the supervision, teaching, custody of, or access to minors at Lifepoint Church, as well as other sensitive roles. All information will be treated with utmost confidentiality.
Name
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First Name
Last Name
Middle Name
*
Please list any other names that have been used, including maiden/previous married name (type NA if non applicable)
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Date of Birth
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-
Month
-
Day
Year
Date
Gender
*
Male
Female
Email Address
*
Current Physical Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Current Mailing Address (if different)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone
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Area Code
Phone Number
Cell Phone
*
-
Area Code
Phone Number
SS#
*
Driver's License Number
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Driver's License State
*
Marital Status
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Single
Married
Widowed
Spouse's Name (if married)
Dream Team Member Campus
*
Culpeper
Fredericksburg
King George
Richmond
Spotsylvania
Stafford
In which area(s) are you interested in serving? Please mark any below
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Care/Benevolence
Prayer Team
Counting Team
Security Team
DT Connections
Staff Internship
Group Leader
Students Team
Kidspoint Team
Team Leader
Lifepoint Staff
Trucker Team
Photo/Video
BACKGROUND
(Your answers will not necessarily qualify/disqualify you from serving)
Have you ever been accused , arrested, charged, indicted, or convicted for any criminal offense (felony or misdemeanor) other than a minor traffic violation?
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Yes
No
If yes, explain (type N/A if non applicable)
*
Have you ever had your driver's license suspended, restricted, or revoked for any reason?
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Yes
No
If yes, explain (type N/A if non applicable)
*
Have you ever been accused, arrested, or convicted of child abuse, neglect, or a crime involving actual or attempted sexual molestation of a minor, sexual harassment, or other sexually related crimes?
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Yes
No
If yes, explain (type N/A if non applicable)
*
Do you use illegal drugs?
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Yes
No
Have you ever been hospitalized or treated for alcohol or substance abuse (including prescription drugs)?
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Yes
No
Are there any circumstances involving your lifestyle, background, or personal history that may hinder you from ministry with children or students?
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Yes
No
If yes, explain (type N/A if non applicable)
*
RELEASE & PERMISSION
I understand and agree that: 1. All information I have provided may be verified. I agree to release from liability any and all persons or organizations that provide information regarding me, including these persons I have listed as references. I do hereby agree to indemnify and hold harmless Lifepoint Church of Fredericksburg, Virginia, its employees, representatives, and agents from any claims or causes or action relating in any manner to the verification of or attempts to verify the information provided, attempts to contact references, or conversations with any references. I understand that any information received will not necessarily be disclosed to me, and I hereby waive any right I have to inspect any information provided about me by any person or organization identified by me on this form. 2. By signing this form, I certify and affirm that the information I have given is true, complete,and correct in all respects. 3. I hereby give my permission for Lifepoint Church of Fredericksburg, Virginia to obtain information relating to my criminal history record through the appropriate agency. The criminal history record, as received from the reporting agencies may include arrest and conviction data as well as plea bargains and deferred adjudications. I understand this information will be used, in part, to determine my eligibility for a volunteer position with the church. I also understand that I will have the opportunity to review the criminal history, and a procedure is available for clarification if I dispute the record as received. I, the undersigned,do for myself and heirs, executors, and administrators, hereby release and forever discharge and agree to indemnify the investigating agency and each of their officers, directors,employees, and agents and hold them harmless from and against any and all causes of actions, suits, liabilities, costs, debts and sums of money, claims and demands whatsoever, and any and all related attorney’s fees, court costs, and other expenses resulting from the investigation of my background in connection with my application to become a volunteer.I further state that I have carefully read the foregoing release and know the contents thereof and voluntarily sign this release as my own free act. This is a legally binding agreement which I have read, understood, and accept.
Applicant's Name
*
First Name
Last Name
Applicant's Signature
*
Today's Date
*
-
Month
-
Day
Year
Date
Submit
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