Name *
Name
Have you ever been convicted of a criminal offense (felony or misdemeanor, except for minor traffic violations)? You will need to answer "yes" if you have entered into a plea agreement, including a deferred sentence or deferred judgment arrangement, in connection with a criminal charge.
If you have been convicted of such an offense, please give us the nature of the offense, date, court where conviction was entered, and any other relevant information.
Have you ever been arrested for or charged with a sexual offense, offense relating to children, or crime of violence (that is not covered in question above)?
If you have been arrested for or charged with such an offense, please give us the nature of the offense charged, law enforcement agency making the charge, and any other relevant information.
Have you ever been reported to a social services agency, law enforcement authority, child abuse registry, or similar organization regarding abuse or misconduct involving children or adults?
If yes, give the date and complete description of the circumstances, the name and address of the church, employer, or other organization involved, and the name and telephone number of a person familiar with the circumstances.
Have you ever been subjected to expulsion, reprimand, or other discipline by a church, denomination, or other religious organization?
If yes, give the date and complete description of the circumstances, the name and address of the church, employer, or other organization involved, and the name and telephone number of a person familiar with the circumstances.
Have you ever been the subject of a civil lawsuit involving sexual misconduct, sexual harassment, or other immoral behavior or conduct, involving adults or children?
If yes, give the date and complete description of the circumstances, the name and address of the church, employer, or other organization involved, and the name and telephone number of a person familiar with the circumstances.
Have you ever been the subject of a complaint or disciplinary proceeding against a professional license or other license held by you, including but not limited to a license to provide child care or similar services?
If yes, give the date and complete description of the circumstances, the name and address of the church, employer, or other organization involved, and the name and telephone number of a person familiar with the circumstances.
Have you ever been the subject of any disciplinary action, transfer, or dismissal, or been named as a defendant in a civil or criminal lawsuit, as a result of an accident or mishap involving children or adults?
If yes, give the date and complete description of the circumstances, the name and address of the church, employer, or other organization involved, and the name and telephone number of a person familiar with the circumstances.
Have you ever been subject to any disciplinary action (including discharge) or investigation by a church, religious or other organization, or by an employer?
If yes, give the date and complete description of the circumstances, the name and address of the church, employer, or other organization involved, and the name and telephone number of a person familiar with the circumstances.
Have you ever been subject to any disciplinary action, transfer or dismissal or been named as a defendant in a civil or criminal lawsuit due to any financial irregularity, mishandling of, or misappropriation of the funds of any organization or ministry?
If yes, give the date and complete description of the circumstances, the name and address of the church, employer, or other organization involved, and the name and telephone number of a person familiar with the circumstances.
I certify that the information I have given on the Background Disclosure is correct and accurate. I understand my failure to provide complete, accurate and truthful information on this document will be grounds to dismiss me from my internship.
Today's Date *
Today's Date