Program Personnel Application Form (Adults)

In our desire to reduce the risk of abuse within Dorion Evangelical Church programs, we believe this information is necessary to protect our Children, Youth, Vulnerable Adults and our Volunteers and to effectively place our Volunteers in Program positions. Thank you in advance for your partnership.

Personal Information

Personal History

Program Information and Experiences

Organizations/Churches I attended in the last five years are as follows:

Information About your Ability to Work with Children, Youth or Vulnerable Adults

In order to provide a safe and secure environment for our Children, Youth and Vulnerable Adults, we believe it is necessary to include the following questions as part of our application process. All information will be kept confidential by Dorion Evangelical Church Leadership team.  (Police may access this information, under warrant, if requested.) Answering yes to any of the questions may not necessarily preclude your involvement in Program. Thank you in advance for your understanding.







References 1

Please provide the names of three individuals, excluding relatives, who could provide a reference for you. Include at least one reference from outside Dorion Evangelical Church.

References 2

Please provide the names of three individuals, excluding relatives, who could provide a reference for you. Include at least one reference from outside Dorion Evangelical Church.

References 3

Please provide the names of three individuals, excluding relatives, who could provide a reference for you. Include at least one reference from outside Dorion Evangelical Church.

Release of Information and Declaration of Intent

I hereby give Dorion Evangelical Church consent to verify the information provided by me in this Program Personnel Application Form and to contact the references and current and former employers listed above and to obtain and verify any information from them (and any other persons that Dorion Evangelical Church determines might be able to provide relevant information) that may be relevant to my application.

I grant my permission for Dorion Evangelical Church to perform a police records check on me, and I will sign and return the attached “Release of Information and Declaration of Intent” for such purpose.

I further grant Dorion Evangelical Church permission to perform an internet search on me and to review and consider any information found by me on the internet.

I understand that if Dorion Evangelical Church approves my volunteer application and later determines, in its discretion, at any time that I am not suitable for volunteer service in Dorion Evangelical Church or for the volunteer position for which I am applying, Dorion Evangelical Church may terminate my volunteer service or volunteer position for any reason without advance notice.

If Dorion Evangelical Church approves my application for a volunteer position, I will sign any documents that the organization requires and will at all times cooperate fully with the staff of Dorion Evangelical Church in the fulfillment of my duties and will keep all confidential information I encounter in my role as a volunteer confidential.

If at any time I determine that for any reason I am unable to support or adhere to or follow the policies and
procedures of Dorion Evangelical Church, I will inform the organization and will resign my volunteer position.

I hereby acknowledge that, to the best of my knowledge, the information contained in this Program Personnel Application Form is true and correct.

Information received is confidential and is being gathered for the purposes of screening Program Personnel and placing them into Program with Children, Youth and Vulnerable Adults.  The information gathered here will be used for the purposes of supporting the programs at Dorion Evangelical Church.
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