Do NOT

use
staples

Duplicate forms as needed; PLEASE DO NOT make back-to-back copies of adult application and pastor reference

Potomac CE Power Up Retreat 2015

Adult Registration & Pastor Reference, Page 1 of 2

This application is to be completed by all adult leaders attending the retreat. After you have completed in FULL your portion of the
application, give this form to your pastor for his/her reference. He/she will submit it with your churchs registration.

APPLICANTS PERSONAL INFORMATION

FIRST NAME

MIDDLE NAME

LAST NAME

Name you want on NAME BADGE (Miss Sue, Pastor Jim etc)
AGE
SEX
M
F
E-MAIL ADDRESS
An email address is required for all confirmations and correspondence.
STREET ADDRESS (Cannot Use PO Box)
CITY
ST
ZIP CODE
home cell work church
DAYTIME PHONE NUMBER (area code + number)
home cell work church
EVENING PHONE NUMBER (area code + number)
CHURCH
CITY
ST
PRESENT OCCUPATION
Have you previously served at a Potomac District Camp or Retreat?
YES NO When?
Are you certified in/as a Lifeguard
CPR
EMT
LPN
RN Certified in what state?
CHRISTIAN LIFE & MINISTRY

Are you comfortable praying with children?

YES

NO

CRIMINAL BACKGROUND INFORMATION

Yes No Have you ever been convicted of a criminal offense (excluding traffic tickets)? If YES, explain on separate sheet of paper.
Yes No Have you ever been convicted of a child abuse, neglect or molestation? If YES, explain on separate sheet of paper
Yes No Have you ever been hospitalized for drug or alcohol abuse? If YES, explain on separate sheet of paper.
Yes No Do you voluntarily consent to a background check? If NO, we cannot accept you as a chaperone.
In order to provide a safe and secure environment for students, it is necessary for us to require a background check on all adult leaders. If you are
not a credentialed A/G minister or your church does not have a criminal background check on file for you, a current street address (above) along
with the following information is required for us to run a check.

DATE OF BIRTH (mm/dd/yyyy)

SS#
ADULT LEADER SIGNATURE OF COMPLIANCE

The information contained in this application is correct to the best of my knowledge. I authorize my pastor to give you any information (including opinions) he/she may have regarding
my character and fitness for childrens ministry. In consideration of the receipt and evaluation of this application by the Potomac District Council, I hereby release any individual,
church, youth organization, charity, employer, reference, or any other person or organization, including record custodians, both collectively and individually, from any and all liability
for damages of whatever kind or nature, which may at any time result to me, my heirs, or family, on account of compliance or any attempts to comply, with this authorization. I waive
any right that I may have to inspect any information provided about me in this application. Should my application be accepted, I agree to be bound by the Constitution and Bylaws
and policies of the Potomac District Council of the Assemblies of God, and to refrain from any unscriptural conduct in the performance of my services on behalf of the Potomac
District Council.

ADULT LEADERS LEGAL SIGNATURE:

Potomac CE Power Up Retreat 2015

Adult Leader Application & Pastoral Reference, Page 1 of 2

Do NOT
use
staples

Duplicate forms as needed; PLEASE DO NOT make back-to-back copies of adult application and pastor reference

Potomac CE Power Up Retreat 2015

Adult Registration & Pastor Reference, Page 2 of 2

Reference must be completed by a pastor, staff or board member NOT related to applicant.
PASTOR REFERENCE
NAME OF APPLICANT:
The above-named applicant has given written authorization to obtain from you any information you might have regarding the applicants character and fitness for
working with children. The applicant has further released you from liability for any damage that may result from your furnishing us with such an evaluation. We
would appreciate your complete and confidential answers to the following questions and the return of this form to the Potomac District Christian Education
Department with your churchs registration. The applicants registration CANNOT be processed further unless you complete this section. Thank you!
REFERENCE QUESTIONS
1. How long have you been acquainted with this applicant?
2.

Is he/she a fully devoted follower of Jesus Christ?

Yes

No If No, explain:

3.

What experience in your church does he/she have with children? Explain:

4.

Has he/she ever had problems in dealing with children?

5.

Is there anything in his/her character that would exempt him/her from working with children?

6.

Does he/she have any emotional, mental or physical handicaps that would hinder his/her participation or effectiveness?
No If Yes, explain:

7.

To your knowledge, has he/she ever been accused of child abuse, neglect or molestation?

Yes

No If Yes, explain:

8.

To your knowledge, has he/she ever been convicted of child abuse, neglect or molestation?

Yes

No If Yes, explain:

9.

To your knowledge, has he/she ever been convicted of a crime (excluding traffic ticket)?

Yes

No If Yes, explain:

10. Would you trust this person with your own children/grandchildren?

Yes

Yes

Yes

No If Yes, explain:

Yes

No If Yes, explain:

No If NOT, explain your reservations:

11. What kind of addition to our district kids ministry do you believe this applicant would be:

Excellent

Good

Fair

Poor

BACKGROUND CHECK: Please select ONE of the following statements

We have completed, and have on file, a criminal background check on this applicant. Date of last check:
This applicant is a credentialed A/G minister. A background check is on file with his/her A/G credentials application.
We do NOT have a criminal background check on file; a background check must be ordered by the district for this applicant.
PASTORS RECOMMENDATION: Please select ONE of the following statements
I hereby recommend without reservation the above named applicant.
I hereby recommend with reservation the above named applicant. Please explain below.
I hereby CANNOT recommend the above named applicant.
Comments:

PASTORS SIGNATURE: Please complete, sign and send this form even if you cannot endorse this applicant.

Pastors Name (Please type or print legibly):

PASTORS SIGNATURE:

Potomac CE Power Up Retreat 2015

Adult Leader Application & Pastoral Reference, Page 2 of 2