Safe Sanctuary Annual Renewal Form | St. Luke's United Methodist Church

Program(s) for which you are applying to volunteer*

Children's Ministries
Student's Ministries
St. Luke's Day School
P.M. Pals
The Story Houston
Fine Arts
KIDS HOPE

First Name*

Middle (Maiden) Name*

Last Name*

Have you ever gone by another name?*

Yes
No

All other names that have been used by applicant (if any)

Home Phone*

Business Phone*

Cell Phone*

Email*

Present Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Previous Addresses for last 5 years

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of Birth*

Gender*

Female
Male

Do you plan to be a driver?*

Yes
No

Program?

If YES, please include requested information on Authorization form, along with photocopy of license.

Do you use illegal drugs*

No
Yes

Have you ever been charged with child neglect or abuse?*

Have you ever been convicted of or pleaded guilty to a crime (other than minor traffic offenses)?*

yes
no

If yes, please explain, attach separate page if necessary.

Other than the above, is there any fact or circumstance involving you or your background that would call into question your being entrusted with the supervision, guidance and care of young people? (if yes, explain.)*

Please indicate training you have received and date of expiration.

CPR

First Aid

Medical Training

Health issues which might limit your availability to serve

Days and times you are available?

Authorization and Request for Criminal Records Check

I

hereby authorize St. Luke’s Methodist Church to request the relevant police/sheriff’s department to release information regarding any record charges or convictions contained in its files, or in any criminal file maintained on me, whether said file is local, state or national file, and including but not limited to accusations and convictions for crimes committed against minors, to the fullest extent permitted by state and federal law. I do release said police/sheriff’s department from all liability that may result any such disclosure made in response to this request.

Signature

Date

Driver's License Number*

State Issuing License*

State / Province / Region

License Expiration Date*