Background/Reference Check Authorization

This screening form is to be completed by applicants for any position, paid or volunteer, involving CEF® ministries and will be used to help CEF provide a safe and secure environment for children. This is not an employment application. Anyone interested in employment with CEF will also need to complete an employment application form.

Applicant's Name (last, first, middle)

Sex

Date of Birth

Social Security Number

Maiden Name (if applicable)

All Nicknames and Aliases

Telephone

Email

Present street address (Street, Apt #, City, State, Zip; PO Box not acceptable)

County

Previous street addresses (for past five years)

Have you ever been convicted of a crime? YesNo (If yes, please explain and give county and state of conviction.)

Have you ever been accused of child abuse? YesNo (If yes, please explain.)

(If completing form for five-year rescreening, skip this question.) Please explain briefly your salvation experience.

(If completing form for five-year rescreening, skip this.) Is there anything that would call into question your being entrusted with the supervision, guidance and care of children or young people? If yes, please explain.

(Skip for 5-year rescreening.) References (pastor or church leader, previous employer and personal [not a relative])

1. Name
   

   Church
   

   Address
   

   Phone
   

   Email
   

2. Name
   

   Church
   

   Address
   

   Phone
   

   Email
   

3. Name
   

   Church
   

   Address
   

   Phone
   

   Email
   

4. Name
   

   Church
   

   Address
   

   Phone
   

   Email
   

Release Authorization:

1. In connection with my future involvement as a staff member or a volunteer working with children, I understand that CEF® will conduct a background check to determine my ability to minister in this role. It may include information concerning my character, work habits, performance and any court records that may have a bearing on my job responsibilities.
2. I acknowledge that a telephonic facsimile (fax) or photocopy of my signature shall be as valid as the original.
3. I hereby authorize, without reservation, any law enforcement agency, institution, information service bureau, school, employer, church or nonprofit organization, reference, or insurance company contacted by CEF or its consumer reporting agency or its agents, to furnish the information described above.
4. I understand that if any of those records contains information which is used to prevent my involvement in Child Evangelism Fellowship®, I will be notified of my rights and where I can obtain a copy of the information.

By signing below, I hereby release Child Evangelism Fellowship and its agents, officials, representatives, or assigned agencies, including officers, employees, or related personnel both individually and collectively, from any liability for damages of whatever kind, which may at any time result to me, my heirs, family, or associates because of compliance with this authorization and request to release information. I may be contacted as indicated below. A copy of this authorization (if not previously destroyed in accordance with record retention policies) will be given to me, provided I request it in writing.

The information contained in this screening form is correct to the best of my knowledge. I authorize any references listed on this application to give you any information (including opinions) they may have regarding my character and fitness for children's work. I hereby release any individual, church, youth organization, employer, charity, reference, or any other person or organization, both individually or collectively, from any and all liability for damages of whatever kind or nature which may at any time result to me, my heirs or my family on account of compliance or any attempts to comply with this authorization, excepting only the communication of knowingly false information.

I agree to abide by the Child Protection Policy and to refrain from unscriptural conduct in the performance of my services on behalf of CEF.

I have read the Child Protection Policy and viewed (cefonline.com/childprotection) or heard (866-878-4182) the "Protecting Today's Child" presentation and agree to follow the policies and procedures in handling any child abuse situations that may arise.

I further state that I have read carefully the foregoing release and know the contents thereof. This is a legally binding agreement which I have read and understand.

By entering your name below, you acknowlege that you are signing this form:

Date of signature: