This application is to be completed by all applicants for any position (volunteer or compensated) involving the custody of minors or the developmentally disabled. This is not an employment application form. Persons seeking a position in the church as a paid employee will be required to complete an employment application in addition to this screening form. It is being used to help the church provide a safe and secure environment for those children, youth, or developmentally disabled who participate in our programs and/or use our facilities.
This information is used for internal purposes only, by this congregation of the United Methodist Church.
Along with this application, you must read
our policy and complete the online Safe Sanctuary training provided by the Kentucky UMC Annual Conference.
Date of Birth
Social Security Number
Do you agree to a background check?
Time at this employment
Have you ever been convicted of any criminal offense?
If yes, please explain below
Have you ever been charged with or convicted of child neglect or abuse?
Have any complaints or allegations of misconduct involving children ever been made against you?
Have you ever been denied the opportunity to serve in children, youth, or developmentally disabled ministries in the past?
Have you ever been convicted of the possession, sale, or use of drugs?
Within the last 30 days, have you abused alcohol, legal, or illegal drugs?
Have you been convicted or plead guilty to a traffic offense in the past five years?
Do you hold a current driver's license?
If yes, give your license number
Are there any facts or circumstances, in addition to the above, involving you and your background that would call into question your being entrusted with the supervision, guidance, or care of young people?
If yes, please explain
Name of the church where you are a member
List other churches you have attended regularly in the past 5 years. Please give names, addresses, and dates.
List all previous church or other organization work involving children, youth, or developmentally disabled persons
List any gifts, callings, training, education, or other factors that have prepared you for children, youth, or developmentally disabled ministry
The information contained in this application is correct to the best of my knowledge. I understand it may be cause for dismissal if it is found the answers given are untrue. I authorize any references or churches listed in this application to give you any information, including opinions that they have regarding my character and fitness for children, youth, or developmentally disabled ministry. In consideration of the receipt and evaluation of this application by Wilmore United Methodist Church, I hereby release any individual, church, youth organization, charity, employer, reference, or any other person or organization including record custodians, both collectively and individually, from any and all liability for damages of whatever kind or nature which may at any times result to me, my heirs, or family on account of compliance or 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 be bound by the Bylaws of Wilmore United Methodist Church, and to refrains from unscriptural conduct in the performance of my services of behalf of the church.
(By typing your full name, you agree to the above statement) *
I have asked the following persons, not relatives, to submit a reference form on my behalf. Please list at least one former or present employer, if possible. I waive any and all rights to view these references at any time.
Name of Reference 1
Phone Number of Reference 1
Address of Reference 1
Name of Reference 2
Phone Number of Reference 2
Address of Reference 2
Name of Reference 3
Phone Number of Reference 3
Address of Reference 3
link will direct you to a reference form that needs to be completed by the references you have listed above. If the reference would rather a print form, please download and print pages 5–6 of the application form here and mail the completed form to the address below. Please remember that you have waived your right to see these reference forms.
Reference Form—Online Form Reference Form—PDF
Missional-Discipleship Pastor Wilmore United Methodist Church 209 East Main Street Wilmore, KY 40390