WPC 0yn4Ā@]5ED@|)CI=GX5v\Ao6WԂ?a qݚx:rM̳פy@7="ET}vXJf^{a-tOhBƒԢnT1j~Mw ^!Ӫ%Lvm4|Eޫu &jH- 騨jF3Ou٢wP 7֞X.鯣 ]0h W"v jTc*Ywh\ ӂ.~s3DqŅ\[޵*Ԝ-AÒj)FϺ3[h*#"h߼f-XzNK`kpr> ~/es i?[(C}VS ' %$5uuVC; =11X ;f|qɶ1U6 %6 U:< 0Cv v 0C  n #! 0( N 1u 0 cy ^ ^ w@ 44 H mJ a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a B D3/ D3b B  D3 B D3 B5 D3R B D/ D3 B* D3. B*aaaaaaaaaaaaaaaaaaaaa DKP4 `(Roman10 CPI,AZ"Arial Regular(2I$  !  (2I$  !  #|x) P4 `(Roman10 CPIx4 @[ @HP LaserJet 5 (Copy 2),,,,0($##37=CIQYag1.a.i.(1)(a)(i)1)a)(;3$2#  0  .3  0  +)Z+) b$E%&'(D)D&)+00U I)  _X8XӀ̀ d\\\\'dxd____'dxd  daaaa'dxdP Pdcccc'dxd deeee'dxd daa' dxdhhhh'dxd&0 d djjjj'dxd&P d d____?Heavy ShadowdZd  !  _XXXHHHHTRX3'X3' Letter3' Letter3'TX   TT5iH5_)Application)__)and)__))Screening_ԀFormfor'Volunteers'(Employees(inYouthWork#T##nTf#  q Z=nXfhX=  ChristOurShepherdLutheranChurch  101_Peachtree_ԀParkwayNorth_Peachtree_ԀCity,GA30269i@S qqqq!@-OXXfhThisscreeningformistobecompletedbyallpersonsinvolvedinanywaywithsupervisionoforcontactwith 9  childrenundertheageof18. Allinformationonthisformwillbekeptconfidential.    OurmissionistoglorifyGodandwitnessourfaithtoall:  =   SavedbyGodsgrace  SurroundedbyGodslove  SustainedbyWordandSacraments  Senttoserve.ThanksbetoGod!InkeepingwiththismissionChristOurShepherdseekstoprovideanenvironmentsafefromphysicalandsexualabuse.     3   5M5 32#  1  .3  0    Adultswhohavebeenconvictedorareguiltyofeithersexualorphysicalabuseshouldnotworkinany  churchsponsored @ activityorprogramforchildren,youth,orvulnerableadults. 3o݌ $$ Ќ    3    3 2#  2  .3  0    Adultswhohavebeenviolatedphysicallyorsexuallyneedthe @ loveandacceptanceofthischurch.Itisour {3 hopethatany @ previouslyviolatedadultswhoareconsideringworkingwithchildren,youthorvulnerableadultshavetherapeuticallyresolvedanyissuesintheirpastwhichmightnegativelyaffect @ theirwork.Iftheseissuesareresolved,weofferourcommendation.Iftheyarenot,wepraytheywillacceptourhelpbyconnectingthemwithapastor. 3  ݌ $$ Ќ    3    3 2#  3  .3  0    AllemployeesofChristOurShepherdwhoworkwithchildrenare @ presumedtohaveacommitmenttoJesus f Christandthechurch. 3 ݌ $$ Ќ    3    3 2#  4  .3  0    AllemployeesofChristOurShepherdwhoworkwithchildrenare @ expectedtoknowandabidebythe   policiesandproceduresof @b ChristOurShepherd. 3 (݌ $$ Ќ  @FW*AA!:@@  XfhX-OPersonalInformation   Date:________________HomePhone#________________________________________LastName__________________________Middleormaidenname_____________________FirstName______________________(Identitymustbeconfirmedwithastatedriverslicenseorotherphotographicidentification.) "#$ StreetAddress________________________________________________________________City__________________________________State____________Zip_________________Doyouhaveavaliddriver'slicense?Yes_____No_____Ifyes,pleaselistyourdriver'slicensenumber_______________________Doyouhaveanyphysicallimitationsormedicalconditionswhichmightaffectyourabilitytoworkwithinfantsandchildren?Yes_____No_____Ifyes,pleaseexplain____________________________________________________________________________________________________________________ .+1 _ԇHaveyoueverybeenconvictedoforcommittedacrimeinvolvingabuse?no_______yes_______(Ifyes,pleaseexplain.Youmaywriteonthebackofthisformifnecessary.)______________________________________________________________________________________________________________________________________________________@  @@  ChurchHistoryandPriorYouthWork  d Nameandaddressofchurchwhereyoucurrentlyholdmembership______________________________________________________________________________________________________________________________________________________Listthename(s)andaddress(es)ofchurchesyouhaveattendedregularlyduringthepastfiveyears:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________Listallpreviouschurchworkinvolvingyouth(listeachorganization'snameandaddress,typeofworkperformedanddates)________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Listallpreviousnon-churchworkinvolvingyouth(listeachorganization'snameandaddress,typeofworkperformedanddates)________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Listanygifts,callings,training,educationorotherfactorsthathavepreparedyouforworkwithchildrenandyouth.________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________@  Volunteer'sStatement  r%*"& Theinformationcontainedinthisapplicationiscorrecttothebestofmyknowledge.Igivepermissiontocontactanyreferencesorchurchlistedonthisform.Iagreetobeboundbytheconstitution,bylawsandpoliciesofChristOurShepherdLutheranChurchandtorefrainfrominappropriateconductintheperformanceofmyservicesonbehalfofthe%c%&h&%h%urch.IfurtherstatethatIHAVECAREFULLYREADTHEFOREGOINGRELEASEANDKNOWTHECONTENTSTHEREOFANDISIGNTHISRELEASEASMYOWNFREEACT.ThisisalegallybindingagreementwhichIhavereadandunderstand.Applicant'sSignature____________________________________$___$$񀀀$Date_________________ Z/,1