CEF of south Central Confidential Screening Form Step 1 of 2 50% Date(Required) MM slash DD slash YYYY Name(Required) First Middle Last Maiden Name Last All Nicknames and Aliases Nicknames and Aliases Social Security Number(Required) Sex(Required) Male Female Date of Birth(Required) MM slash DD slash YYYY Phone(Required)Email(Required) Previous Residencies for Past Five Years(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code County Have you ever been convicted of a crime? If yes please explain and give country and state of conviction(Required) Yes No Have you ever been accused of child abuse?(Required) Yes No If yes, please explain and give county and state of conviction.(If completing form for five year rescreening skip this question). Please explain briefly your salvation experienceIs there anything that would call into question your being entrusted with the supervision guidance and care of children or young people? If yes please explain.(Required)Reference Name (1)(Required) First Last Reference Address (1)(Required) Street Address Reference Phone (1)(Required)Reference Email (1)(Required) Reference Name (2)(Required) First Last Reference Address (2)(Required) Street Address Reference Phone (2)(Required)Reference Email (2)(Required) Reference Name (3)(Required) First Last Reference Address (3)(Required) Street Address Reference Phone (3)(Required)Reference Email (3)(Required) Background/Reference Check Authorization(Required) I further state that I have read carefully the foregoing release and know the contents thereof. This is a legally binding agreement which I have read and understand.Background/Reference Check Authorization Release Authorization: 1. In connection with my future involvement as a staff member or a volunteer working with children, I understand that CEF® will conduct a background check to determine my ability to minister in this role. It may include information concerning my character, work habits, performance, and any court records that may have a bearing on my job responsibilities. 2. I acknowledge that a telephonic facsimile (fax) or photocopy of my signature shall be as valid as the original. 3. I hereby authorize, without reservation, any law enforcement agency, institution, information service bureau, school, employer, church, or nonprofit organization, reference, or insurance company contacted by CEF or its consumer reporting agency or its agents, to furnish the information described above. 4. I understand that if any of those records contain information that is used to prevent my involvement in Child Evangelism Fellowship®, I will be notified of my rights and where I can obtain a copy of the information. By signing below, I hereby release Child Evangelism Fellowship and its agents, officials, representatives, or assigned agencies, including officers, employees, or related personnel both individually and collectively, from any liability for damages of whatever kind, which may at any time result to me, my heirs, family, or associates because of compliance with this authorization and request to release information. I may be contacted as indicated below. A copy of this authorization (if not previously destroyed in accordance with record retention policies) will be given to me, provided I request it in writing. The information contained in this screening form is correct to the best of my knowledge. I authorize any references listed on this application to give you any information (including opinions) they may have regarding my character and fitness for children’s work. I hereby release any individual, church, youth organization, employer, charity, reference, or any other person or organization, both individually or collectively, from any and all liability for damages of whatever kind or nature which may at any time result to me, my heirs or my family on account of compliance or any attempts to comply with this authorization, excepting only the communication of knowingly false information. I agree to abide by the Child Protection Policy and to refrain from unscriptural conduct in the performance of my services on behalf of CEF. I have read the Child Protection Policy and viewed (cefonline.com/childprotection) or heard (866‐878‐4182) the Protecting Today’s Child presentation and agree to follow the policies and procedures in handling any child abuse situations that may arise. I further state that I have read carefully the foregoing release and know the contents thereof. This is a legally binding agreement that I have read and understand.Signature of Applicant (or parent of minor)(Required) First Last Date(Required) MM slash DD slash YYYY
