Lead Pastor's Name *

First Name

Last Name

Lead Pastor's Phone *

(###)

###

####

Applicants Name *

First Name

Last Name

1. How long have you know this applicant?

Less than 1 year

1 - 2 years

2 - 5 years

5+ years

2. Does this applicant attend all church services faithfully?

Yes

No

4. Has the applicant ever worked with student ages? (check all that apply)

5 - 6 years

7 - 10 years

11 - 12 years

13 - 18 years

5. To your knowledge, has the applicant ever displayed inappropriate behavior towards a minor?

Yes

No

6. Would you feel comfortable leaving your children in his/her care?

Yes

No

8. To your knowledge, is the applicant free from the use of tobacco, alcohol, or other drugs?

Yes

No

9. In the past five years has the applicant had any negative changes in moral, marital, or other life situations?

Yes

No

10. Can you vouch for the moral integrity of this applicant?

Yes

No

11. Does this applicant have adequate spiritual maturity to pray with students in the altar?

Yes

No

12. Has this person been cleared through your church child/adolescent abuse prevention policy?

Yes

No

14. Do you recommend this individual to work at an Arkansas District event?

Yes

No