We appreciate your desire to make a difference in the lives of children and students. Thank you for taking the time to completely fill out this application and authorization for a background check. Please fill out this form fully and completely. Date* Click the calendar icon to pick a date.Sex*MaleFemaleName* First Middle Last Maiden Name (Write N/A if not applicable) Home Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Cell PhoneHome PhoneWork PhoneEmail* Birth Date* Date needs to be 8 digits: mm/dd/yyyyPlease list other states of residence in the past 7 years:*Current work status:*Full TimePart TimeStudentCurrent Employer*Occupation*Marital Status*SingleMarriedDivorcedWidowedHow many years have you been attending Heartland Community Church?*If under a year, please answer "0"I am a...*Believer (I have asked Jesus to be the leader of my life)Seeker (I am asking questions and want to know more about God)Which ministry are you interested in?*Heartland Leadership puts a very high value on the safety of the children we care for and minister to. We know that parents are counting on us to screen every volunteer who works with minors in our care. In caring for minors, we believe it is our responsibility to seek an adult staff that is able to provide a safe, healthy and nurturing learning environment. After we receive your application, we will contact you to set up a short one-on-one meeting with you and one of our Child Protection Program team members. Personal InformationHave you been arrested, convicted, or pled guilty to a crime in the last 7 years? If yes, please choose "other" and explain.*NoHave you ever been accused, charged or convicted of child abuse or neglect, or any crime involving actual or attempted sexual abuse? If yes, please choose "other" and explain.*NoHave you ever voluntarily left or been asked to leave a role within an organization due to a concern regarding inappropriate conduct with minors? If yes, please choose "other" and explain.*NoHave you ever been concerned about or received treatment or support for an addiction to drugs, alcohol or pornography? If yes, please choose "other" and explain.*NoIs there any circumstance or pattern in your life which would make it inappropriate for you to serve with minors? If yes, please choose "other" and explain.*NoDo you have any conditions that may prevent you from performing certain types of activities? (Example: Are you unable to lift toddlers?) If yes, please choose "other" and explain.*NoApplicant's StatementThe information I have given in this application is correct and complete. I understand that any false information or significant omissions I have made on this application may disqualify me from further consideration for service in the ministries of Heartland Community Church. I also authorize Heartland Community to contact any references I have submitted and to conduct background checks that could include review of personal records such as driving, police, department of corrections, court records, etc. I understand that any such information contained in said reports or this application will be held in strictest confidentiality by the professional church staff and designated volunteers.Applicant's Initials*Date* If applicant is between the ages of 16 and 17, parent/guardian signature is required. As this student’s parent/guardian, I affirm and support his/her desire to serve at Heartland. I have read his/her application, and to the best of my knowledge, it is complete and accurate.Parent/Guardian InitialsRelationship to StudentDate By clicking submit on this application, you consent to us performing a background check.* I understand We will need for you to supply your Social Security number in order for us to perform a background check. For security purposes, we are not asking for you to provide your Social Security number on this form. Kim Kopelman, the Director of the CPP program at Heartland, will be contacting you for that information within 5 days of submitting your application. Please provide us with the best phone number to reach you.*Thank you for your interest in serving at Heartland!