Safe Sanctuary Application

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

First Name*

Middle (Maiden) Name*

Last Name*

Have you ever gone by another name?*

Yes
No

What was other name?

Home Phone*

Business Phone

Cell Phone*

Email*

Address*

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Identity must be confirmed with a Texas State Drivers License or other photographic identification.

Upload front of drivers license*

Drop files here or

Accepted file types: jpg, png, pdf.

jpg, png or pdf files allowed

Driver's License Number*

License Expiration Date*

State issuing License*

Date of Birth*

Place of Birth

Gender*

Female
Male

Do you plan to be a driver?*

Yes
No

Program?

Previous residences for the last 5 years

Address #1*

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Address #2

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Current Occupation*

Employer

Employer Address

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

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?

Church History and Prior Volunteer Experience

Are you a member of St. Luke's?*

yes
no

How long have you been a member?

Name of church where you are a member

Name and Address of church you have attended regularly in the last five years

Street Address

Address Line 2

City

State

ZIP Code

List all previous church work involving children/youth

list each church’s name and address, type of work performed and dates

List all prior volunteer opportunities in which you have been involved

i.e., Boy Scouts, Girl Scouts, Children or Youth Sports and etc.

List any gifts, callings, training, education or other factors that have prepared you to work with children or youth

Why do you want to work with children or youth of St. Luke's?

What do you enjoy most about working with children/youth?

Personal References

NOT FORMER EMPLOYERS OR RELATIVES

Name*

First

Last

Address*

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Name*

First

Last

Address*

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Name*

First

Last

Address*

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Applicant's Statement

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.

Signature*

Name of Applicant

First

Last

Signature of parent if applicant is a minor*

Signature of witness*

Name of witness

First

Last

Address of witness

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Phone of witness

Date

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.

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

Full Name of Applicant

First

Last

Help and Support

Identity must be confirmed with a Texas State Drivers License or other photographic identification.

Previous residences for the last 5 years

Please indicate training you have received and date of expiration.

Church History and Prior Volunteer Experience

Personal References

Applicant's Statement

Authorization and Request for Criminal Records Check