Worker and Parent/Guardian Application
I. Background Information
First Name*
Middle Name*
Last Name*
Date of Birth*
Address*
City*
State*
Zip Code*
Phone Number*
Email Address*
Have you ever been convicted of any crime similar in any manner to those listed below? If yes, please explain.*
 Indecent assault and battery on a minor child
 Indecent assault and battery on a mentally disabled person
 Rape of an adult or minor
 Child abuse or neglect
 Indecency with a child-with or without sexual contact
 Assault with intent to commit rape
 Kidnapping of a child
 Distribution and/or trafficking of narcotics or other controlled substances
 Intent to commit any of the above crimes
Have you ever been adjudged liable for civil penalties or damages involving sexual or physical abuse of children? If yes, explain.*
Have you ever been convicted of any crime relating in any manner to children and/or your conduct with them? If yes, explain.*
Are you now or have you ever been subject to any order involving sexual or physical abuse of a minor, including, but not limited to a domestic order or protection? If yes, explain.*
Have your parental rights ever been terminated for reasons involving sexual or physical abuse of children? If yes, explain.*
II. Worker and Parent/Guardian Signature
I am applying for work or volunteer services at St. John's Lutheran Church and School and am subject to a background check which may include a criminal history check, driving record check and sex registry check. I understand that the results of background checks which determine my eligibility are kept confidential and filed in a secure location.
Work or volunteer service of any kind may be denied if I...

--Am found to have a history of complaints of abuse of a minor and/or
--Am found to have a criminal background that is cause for concern and/or
--Am found to have resigned, been terminated or been asked to resign from a position whether paid or unpaid, due to complaint(s) of sexual abuse of a minor and/or
--Make any false statement on this application.
Regarding the statements in Section II,*
 I agree with each of the above statements.
 I do not agree with one or more of the above statements.
Please initial below to indicate agreement with the following statement: I have been provided with a copy of the St. John's Lutheran Church and School policy entitled "Requirements of Employees and School Parents/Guardians." I have read the policy and understand it was established for the protection of any children and youth to whom St. John's ministers, as well as to protect the ministry, workers, parents/guardians and children from unwarranted accusations and lawsuits. *
III. Driver Information Form
If you are applying to be a driver on St. John's School field trips, please complete the following section. If your volunteer service does not include driving, please select "N/A" for each question below and sign and date at the bottom of this form.
I am twenty-one years of age or older.*
 Yes
 No
 N/A
I have a valid driver's license recognized by the State of Wisconsin.*
 Yes
 No
 N/A
I have an adequate number of seat belts for all passengers in my vehicle and require they be worn at all times.*
 Yes
 No
 N/A
I have insurance coverage as required by the State of Wisconsin.*
 Yes
 No
 N/A
I have never been convicted of and/or are not involved in an investigation of a crime that injured or endangered the physical or emotional health or well-being of a minor child.*
 True
 False
 N/A
To the best of my knowledge, the vehicle listed below has nothing in disrepair that would jeopardize the safety of my passengers.*
 True
 False
 N/A
I agree to travel to the destination and back using the safest and most direct route, making no stops that are not included on the permission slip signed by the parents or on the designated itinerary, unless an emergency arises as described below.*
 Yes
 No
 N/A
In the event of accident or illness, I will proceed to the nearest hospital or safe stop and immediately get in touch with the activity leader and/or emergency personnel.*
 Yes
 No
 N/A
Driver's License #
State
Make/Model/Year of Vehicle
License Plate
Name of Automobile Insurance Company
Policy Number
Please enter your full name. This will serve as your electronic signature.*
Date*
This form must be completed annually.


Submit