Please carefully fill in all required boxes with the correct information or the form will not process. Thank you.
List the churches you have attended the past five years;
include the name of a pastor who knows you.
The following questions are asked to all adults,
in order to insure a safe and protected environment for
the children. All answers will be confidential.
All references must have known you for six months. No family members. One reference must attend Ekklesia.
Reference Waiver/ Interview Agreement
By entering my initials and today's date below I certify that all of the above information is true to the best of my knowledge and I waive the right to inspect references and the right to hold the church liable for damages that may result from such evaluations. I also understand that I cannot serve anywhere in Ekklesia Kids without approval of the Ekklesia pastors and elders and that this approval will require a background check with the State of Oregon.
Ekklesia Kids Procedures Agreement
By entering my initials and today's date below I acknowledge that I have read the Ekklesia Kids Procedures packet. To the best of my ability, and by the power of the Spirit, I commit to following these procedures as I work with the children to help them fall more in love with Jesus Christ. I understand that failure to follow such procedures may result in my removal from Ekklesia Kids.
Criminal History Authorization
In order to protect the children who attend Ekklesia, the pastors and elders require the name of every new adult volunteer in Ekklesia Kids to undergo a criminal history background check. Information provided by this report will not necessarily disqualify a candidate from serving in Ekklesia Kids. No applicants will be allowed to serve in Ekklesia Kids until the background check is completed. All information received will be kept confidential and only available to the pastors.
[If you are under 18 years of age, we will not run a background check on you. Please put "N/A" in each box.]
By my signature below, I hereby authorize Oregon State Police to release any information, which pertains to any record of conviction, in its files or in any criminal file maintained on me whether local, state or national. I hereby release OSP and Ekklesia from any liability resulting from such a disclosure.
I understand that I may obtain a copy of the Criminal History Report and will be given the opportunity to challenge the accuracy and completeness of this report and obtain a prompt determination as to the validity of the challenge before a final determination is made by Ekklesia. I also understand that in accordance with Ekklesia Kids’ policies, a new background check will be run every two years if I continue to serve in Kids.