CPP

Pender United Methodist Church Application and Annual Renewal (AAR) Form for Volunteers Working with Children and All Paid Staff

At Pender United Methodist Church (PUMC) our children and their safety is a top priority. In compliance with our Child Protection Policy (CPP) we ask you to complete this AAR and thank you for your cooperation and service.
Your Full Name*

PrefixFirst NameMiddle NameLast Name
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number*
Please Use Dashes
Work Phone Number
Please Use Dashes
Cell Phone Number*
Please Use Dashes
Email Address*
example@example.com
PUMC Role / Volunteer Position (Check all that apply):*

Paid StaffSunday School / Children’s ChurchNursery / Child CareYouth / JLUPender Hill School / Mother’s Day OutMission TripsMusic MinistryVacation Bible SchoolOther
Questions for Self-Certification—All Yes answers require explanation
1. Have you ever been convicted of or pled guilty to, or have charges pending concerning any crime or misdemeanor involving actual or attempted child abuse or neglect or sexual molestation in Virginia or in any other jurisdiction,including, but not limited to murder, abduction for immoral purposes, sexual assault, sexual abuse, sexual exploitation, failing to secure medical attention for an injured child, pandering, crimes against nature involving children,taking indecent liberties with children, neglect of children, obscenity offenses, or similar sexual act or other moral impropriety involving children? *

YesNo
More information on Question 1
2. Have you ever been convicted of or pled guilty to, or have charges pending concerning a felony of any type that has not been expunged? (Note: conviction of a crime that does not involve any risk to children or youth is not an automatic bar to volunteer service or employment with PUMC)*

YesNo
More information on Question 2
3. Have you ever abused a minor or engaged in any conduct that could be regarded as child abuse or neglect, but not limited to murder, abduction for immoral purposes, sexual assault, sexual abuse, sexual exploitation, failing to secure medical attention for an injured child, pandering, crimes against nature involving children, taking indecent liberties with children, neglect of children, obscenity offenses, or similar sexual act or other moral impropriety involving children?*

YesNo
More information on Question 3
4. Because we take very seriously our responsibility to protect the children who participate in our programs and use our facilities we may consult various crime and/or child abuse databases including Sex Offender Registry. Do you have any reason to believe that an investigation on you would disclose any negative information related to children?*

YesNo
More information on Question 4
5. Is there any other information that might be relevant to assessing your fitness for working with children and youth?*

YesNo
More information on Question 5
Applicant’s Statement and Verification (check all and affirm below)
Applicant’s Signature. (Sign with mouse or trackpad)*

Clear
Applicant's Typed Signature*
Today's Date*

MonthDayYear
Thank you for your cooperation and service to Pender's children and youth!
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Pender United Methodist Church Application and Annual Renewal (AAR) Form for Volunteers Working with Children and All Paid Staff