Language
English (UK)
Safe Ministry Screening Questionnaire
For all staff and volunteers
Please Note: This is a sensitive document that will be stored in a confidential manner accessible only by a limited number of authorised persons.
Personal details
Full Name
*
First Name
Middle Name
Last Name
Previous Name(s)
If applicable
Date of Birth
*
/
Day
/
Month
Year
Date Picker Icon
Age
*
15 or younger
16 or 17
18 or older
If you are under 18, what type of role are you applying for?
Junior
Non-junior
Are you applying for a role in pastoral ministry, leadership or engaged in child-related work or work with vulnerable adults?
Yes
No
Working With Children Check (WWCC) number (if required)
Address
*
Street Address
Street Address Line 2
Suburb
State
Post Code
Phone Number
*
E-mail
*
example@example.com
Do you have any health conditions that we should know about?
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Screening Questions
All staff and volunteers
Have you ever been charged with and/or convicted of a criminal offence?
*
Yes
No
To your knowledge, has there ever been any allegations made against you regarding any abuse of a child, physical abuse or sexual misconduct?
*
Yes
No
Have you had a history of alcohol abuse or substance abuse (including prescription, over the counter, recreational or illegal drugs)?
*
Yes
No
For staff and volunteers 18 and over
As an adult (18+ years) have you ever engaged in any of the following conduct:
Yes
No
- sexual contact with someone under your care other than your spouse (such as a parishioner, client, patient, student, employee or subordinate)?
- use, possession, production or distribution of child abuse material?
- sexual contact with a person under the relevant age of consent?
Have you ever had an apprehended violence order, order for protection or the like issued against you as a result of allegations of violence, abuse, likely harm, harassment, stalking, etc?
Yes
No
Has your driver’s licence ever been revoked or suspended? (only applicable if the ministry role may involve driving)
Yes
No
Not Applicable
For staff and volunteers (18 and over) in pastoral ministry, leadership or engaged in child-related work or work with vulnerable adults
Have you ever had permission to undertake paid or voluntary work with children or other vulnerable people refused, suspended or withdrawn in Australia or any other country?
Yes
No
Has a child or dependent young person in your care ever been removed from your care by relevant authorities?
Yes
No
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History and Referees
List any churches you have attended regularly in the past 3 years
*
Name of Church
Location
When (month/year)
Any positions held
1
2
3
Please provide details of two referees who are over eighteen years of age and able to give a verbal report on your character and suitability for ministry. Referees may be part of the church.
*
Full Name
Phone
1
2
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WORKING WITH CHILDREN CHECK AND/OR NATIONAL POLICE CHECK
I consent to verification of my WWCC number (if required, 18+ only)
I consent to a National Police Check (for staff only)
CONSENT TO HOLD INFORMATION
*
Yes
I consent to the information contained in this application, including any subsequent pages, to be kept by our church.
I understand that this information will be kept in a confidential file and used only for screening purposes.
DECLARATION
I, {fullName3} sincerely declare that:
*
Check all boxes
The information I have provided in this application is true and correct to the best of my knowledge and belief.
I understand that if I provide false or misleading information or withhold relevant information from this questionnaire, the church leadership may determine that I am unsuitable to serve in any role in the church.
I have received a copy of the Code of Conduct and am willing to uphold it.
Applicant's signature
*
Clear
If applicant is under 18
Name of Parent or Guardian
First Name
Last Name
Parent/Guardian Contact Phone
Please enter a valid phone number.
Parent/Guardian Signature
Clear
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