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St. Luke’s Day School’s Safe Sanctuary Initial Application
Rachel Green
2022-09-19T10:53:36-06:00
SLDS Safe Sanctuary Initial Application
Personal Information
Apply to become an approved St. Luke’s Day School volunteer. Volunteers must renew annually. Please note, parents who are approved through St. Luke’s UMC Safe Sanctuary are automatically approved for SLDS and do not need to complete this form.
Name
(Required)
First
Middle
Last
Maiden (Put N/A if not applicable)
Cell Phone
(Required)
Email
(Required)
Enter Email
Confirm Email
Enter all other names that have been used by applicant (if any):
Address
(Required)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Country
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Any other addresses for the past 5 years:
(Required)
Date of Birth
MM slash DD slash YYYY
Driver's License or other government issued id number:
(Required)
Social Security Number
(Required)
Expiration Date if any:
MM slash DD slash YYYY
State/Government Issuing:
(Required)
Place of Birth:
(Required)
Gender
Female
Male
Current Occupation, Employer, Employer Address and Phone Number
(Required)
Do you use illegal drugs?
(Required)
Yes
No
Have you ever been charged with child neglect or abuse?
(Required)
Yes
No
Have you ever been convicted of or plead guilty to a crime (other than minor traffic offense)?
(Required)
Yes
No
Other than the above, is there any fact or circumstance involving you or your background that would call into question you being entrusted with the supervision, guidance, and care of young people? (if yes, explain)
Health Issues which might limit your ability to serve?
(Required)
Prior Volunteer Experience
Are you a member of St. Luke's United Methodist Church?
(Required)
Yes
No
List prior volunteer opportunities in which you have been involved (i.e., Boy or Girl Scouts, Children or Youth Sports and etc.)
(Required)
List any gifts, callings, trainings, education or other gifts/talents that have prepared you to work with children:
(Required)
Applicant's Statement
You might be asked to see your driver's license or government issued ID prior to volunteering. SLDS and/or SLUMC will conduct a criminal records check on all applicants at least annually.
Applicant Statement
(Required)
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 and St. Luke's Day School, 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.
I agree to this statement
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.
Applicant's Signature (Please Type your Name)
(Required)
Today's Date
(Required)
MM slash DD slash YYYY
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