Where would you like to serve? *

Nursery Volunteer

City Kids Volunteer

Name *

First Name

Last Name

Maiden Name *

First Name

Last Name

Present Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Cell Phone *

(###)

###

####

Date of Birth *

MM

DD

YYYY

Do you use tobacco products? (For Nursery applicants only) *

Yes

No

Do you use non-prescription drugs? *

Yes

No

Have you any physical handicaps or conditions preventing you from performing certain types of activities? *

Yes

No

Have you ever been convicted of a criminal offense (excluding minor traffic violations)? *

Yes

No

Have you ever been accused of any improper conduct relating to a child or youth, including sexual molestation? *

Yes

No

The information in this form is true and correct to the best of my knowledge. By checking this box, I consent to a background check and national sex offender search. I agree to refrain from any inappropriate conduct in performance of my service to City On A Hill Church. *

I consent