NOT FORMER EMPLOYERS OR RELATIVES

The information contained in this application is correct to the best of my knowledge. I authorize
any references or churches listed in this application to give you any information, including
opinions that they may have, regarding my character and fitness for working with children, youth
or vulnerable adults. In consideration of the receipt and evaluation of this application by St. Luke’s
United Methodist Church, I hereby release any individual, church, youth organization, charity,
employer, reference or any other person or organization, including record custodians, both
collectively and individually, their heirs and assigns, from any and all liability for damages of
whatever kind of nature which may at any time result to me, my heirs, or family, on account of
compliance of any attempts to comply, with this authorization. I waive any right that I may have
to inspect any information provided about me by any person or organization identified by me in
this application.
Should my application be accepted, I agree to read and be bound by the attached Child, Youth, and
Adult Safety Policy for St. Luke’s United Methodist Church and to refrain from conduct in violation
of the attached policies in the performance of my services on behalf of the church.
I further state that I HAVE CAREFULLY READ THE FOREGOING RELEASE AND KNOW
THE CONTENTS THEREOF AND I SIGN THIS RELEASE AS MY OWN FREE ACT. This is
a legally binding agreement which I have read and understand.
This form must be signed in the presence of a witness (not a relative) whose signature appears
below.

A current TX driver’s license must be presented to be copied when this application is submitted. St. Luke’s UMC will conduct a criminal records check on all applicants.