Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth

MM

DD

YYYY

Contact Phone Number *

(###)

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Reference 1 Name *

First Name

Last Name

Reference 1 Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Reference 1 Daytime Phone Number

(###)

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Reference 2 Name *

First Name

Last Name

Reference 2 Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Reference 2 Daytime Phone Number

(###)

###

####

Reference 3 Name *

First Name

Last Name

Reference 3 Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Reference 3 Daytime Phone Number

(###)

###

####

Emergency Contact Name *

First Name

Last Name

Emergency Contact Phone Number *

(###)

###

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How are you connected to Holy Spirit Lutheran Church? *

Member

HSLC friend

Preschool parent or grandparent

Have you ever had your driver's license or other license (professional) suspended or revoked? *

As we go through the volunteer process, we will need a copy of your driver's license or another photo identification. HSLC requires a valid driver’s license or photo id to be on file. If your current driver's license or photo id is expired, you will be contacted to provide another copy

Yes

No

Have you been convicted of, or pleaded guilty or no contest to, any crime? *

Yes

No

Have you ever been investigated by Child Protective Services or the Department of Social and Health Services for alleged child abuse or neglect? *

Yes

No

Have you ever been asked not to attend another church or to cease volunteering with any other organization? *

Yes

No

Is there any fact or circumstance in your background that would call into question the advisability of entrusting you with the supervision, guidance and care of young people? *

Yes

No

Date *

MM

DD

YYYY