Harvest Christian Church

Personal Data

Address History

Church Activity

Personal References

Applicant's Statement

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This application is to be completed by all applicants for any position (volunteer or compensated) involving the supervision or custody of minors. It is being used to help provide a safe and secure environment for those children and youth who participate in our programs and use our facilities. Your signature authorizes Harvest Church to submit a confidential background request through DataSource Background Screening.

Name

Maiden Name

Have you ever been convicted of a criminal offense (excluding minor traffic violations)?

If yes, please explain:

Yes

DOB

SSN

Phone

Have you ever been criminally charged with, investigated for, or civilly sued for any of the following offenses: Rape, sodomy, sexual abuse, contributing to the sexual delinquency of a minor, sexual misconduct, or public indecency?

If yes, please provide the following information: DATE: County of conviction or filing of lawsuit: State of conviction or filing of lawsuit:

Yes