Download a printable version of the Application to Serve form or fill out the form below. Name* First Middle Last Maiden NameDate of Birth* Date Format: YYYY dash MM dash DD Age*Please enter a number from 5 to 100.Gender*FemaleMaleRaceAddress* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneCell PhoneEmail* Number of ChildrenChildren's Ages*Marital Status*SingleEngagedMarriedDivorcedWidowedOccupationPlace of EmploymentWhich campus are you applying to serve*RockfordNorthviewEnsleyWhich ministry or event are you submitting this application for* Kids Guest Services Ladies Bible Study Students Virtual City Easter Drama Wild Wednesday Special Needs Worship Arts Camp Kids' Christmas Mission Trip Other Other ministry or event your interested in*What group you are interested in*5/67/89-12Please indicate age group you are interested in*NurseryPreschoolGrades K-2Grades 3-4Sunday NightsWhat is your preferred time to serve? Check all that apply 9am (Sunday) 10:50am (Sunday) 5:45pm (Sunday) Special Event Only How long have you attended BHBC?*Which campus do you attend regularly?*Do you attend Sunday services regularly?*Are you a member of a church?*YesNoName & location of church*List any churches you have attended in the last 5 yearsList any previous ministry work or leadership rolesPlease list past and current involvement in BHBC ministriesPersonal Testimony of Faith in Jesus Christ*Briefly describe when and how you accepted Jesus personally as your Savior, and how your life is different as a result. Please explain your spiritual journey including any circumstances or people that have influenced you. Personal HistoryPlease explain any ‘yes’ responses in the comments section below. Leaving a question blank will not disqualify you. However, if you would prefer to talk to someone in person about any question in this section, please let us know in the comments.Have you ever been convicted/adjudicated of or pled guilty to a crime?*YesNoHave you ever had any moving violations while driving or any DUI convictions?*YesNoHas there been alcohol abuse, drug abuse, physical or sexual abuse in your family background?*YesNoHave you ever been accused, charged, or alleged to have committed any act of neglect, abuse or molestation of a child?*YesNoHave you ever been concerned that you may have an addiction to drugs, alcohol, pornography or any other addiction, or has anyone ever suggested that you may have a problem with any of the above?*YesNoHave you ever been treated for any type of psychiatric disorder?*YesNoIs there any circumstance or pattern in your life which would make it inappropriate for you to serve with minors or would compromise the integrity of Blythefield Hill Baptist Church?*YesNoDo you have any communicable diseases, such as TB, Hepatitis B, HIV, AIDS, etc.?*YesNoAre you under medication or treatment for any disease or condition?*YesNoCommentsReferencesList three adults you’ve known for at least one year, who are not related to you, and have good knowledge of your character and ability to work with children (if applying for a ministry area that works with children) or with other adults (if applying for adult ministry areas). Please complete all contact information. If any references attend BHBC, just provide their full name.1. Name of BHBC pastor, staff, group leader or member*Relationship*Length of time known*Occupation*Phone*Email* 2. Name of employer or fellow employee*if not employed, list another BHBC member, pastor or group leaderRelationship*Length of time known*Occupation*Phone*Email* 3. Name of friend or neighbor*Relationship*Length of time known*Occupation*Phone*Email* Blythefield Hills Baptist Church (BHBC) runs background checks on all applicants. By signing this form I (the applicant) am authorizing background check information to be released to BHBC. Reports containing details of a crime(s) related to assault, battery, abuse or sexual misconduct will automatically disqualify me from ministry with children. Any other reported misdemeanor or felony will be discussed by BHBC staff with me and may be grounds for denial of my application to work in any ministry setting at Blythefield Hills Baptist Church. The information contained in this application is correct to the best of my knowledge. I authorize any references or churches listed in this application to give any information (including opinions, but excluding unrelated confidential matters) they may have regarding my character and fitness for ministry work. In consideration of the receipt and evaluation of this application by BHBC, 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 by any person or organization identified by me in this application. Should my application be accepted, I agree to be bound by the bylaws of Blythefield Hills Baptist Church and the policies and procedures of the ministry(ies) in which I serve. I further state that I HAVE CAREFULLY READ THE FOREGOING STATEMENT AND KNOW THE CONTENTS THEREOF AND SIGN THIS RELEASE OF MY OWN FREE WILL. This is a legal binding agreement which I have read and understand.Applicant's SignatureParent Signature (for applicants under 18)Applicant Background ScreeningNotice, Authorization, and Release to Obtain Consumer Reports NOTE: Background screening is limited to a criminal history check only. We will not contact your employer. Please return this form with your application and be sure to include your Social Security number. This information is kept in a secured locked location. *Do not fill out if you are age 16 or younger. 1. In connection with my application to serve/work at Blythefield Hills Baptist Church (BHBC), I understand that an investigative consumer report may be requested that will include information as to my character, work habits, work performance, discipline and work experience, along with reasons for termination of past employment. To obtain consumer reports and information concerning my driving, credit, and criminal records, I understand that you may be requesting information from public and private sources about my driving record, education credentials, credit and references. 2. According to the Fair Credit Reporting Act, I am entitled to know if employment is denied because of information obtained by my prospective employer from a consumer-reporting agency. If so, I will be notified and given the name and address of the agency or the source which provided the information. 3. I acknowledge that a telephone facsimile (FAX), electronic or photographic copy shall be valid as the original. 4. I authorize, without reservation, any law enforcement agency, institution, information service bureau, school, employer, reference or insurance company contacted by BHBC or related corporate entities, or its agent, to furnish the information described in Section 1 and waive any right to notice of such disclosure of that information and release. I agree not to sue these entities and their agents as a result of providing such information.Signature (Applicant Background Screening)*Date* Date Format: MM slash DD slash YYYY The following information is required by law enforcement agencies and other entities for positive identification purposes when checking public records. It is confidential and will not be used for any other purposes.Name* First Middle Last Maiden NameCurrent Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Previous Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Social Security Number*Date of Birth* Date Format: MM slash DD slash YYYY Driver's License NumberState Issuing LicenseState Issuing LicenseChild Protection PlanThis set of rules, policies and guidelines apply to all adults and high school students serving in Blythefield Hills Baptist Church (BHBC) ministries involving children age 17 and under. Note: All volunteers must complete a volunteer application and be approved to serve prior to their involvement in BHBC ministries involving children under 18 years of age (herein referred to simply as “students”). Transportation We understand that adults (age 18 and over) may drive students to and from activities. However... All BHBC transportation requires written parental permission for students under 18. (A BHBC Medical form on file is sufficient). No high school drivers may transport students. (Exception: Special arrangements may be made DIRECTLY with parents in writing for a specific purpose). ALL drivers of BHBC vehicles (i.e. vans) MUST be at least 25 years old. Driving alone with the opposite gender should be avoided at all times. All transportation of students assumes the driver of the vehicle has a valid driver’s license, appropriate insurance, properly maintained vehicle, and agrees to drive in a safe manner, including stopping when tired. Small Group Leadership All student small group leaders must have completed a BHBC Volunteer Application and been approved to serve. Volunteers must be a regular attendee of BHBC for at least six months. Junior high groups must have two approved volunteers. If one of the volunteers is in senior high, they may be no less than two grades older than students in their group. A volunteer may not date a student. Intimate or suggestive physical contact is always inappropriate. It is acceptable for a volunteer to take one of his/her group members individually for an activity, but parental approval must be obtained beforehand. Any and all guidelines given by the parent must be followed, such as location, nature of the activity. Emergency contact numbers should also be communicated. Sleep-Over’s The two approved, unrelated adults rule must be followed. As long as any students are awake, one of the volunteers must also be awake to ensure monitoring of safe behavior. Separate sleeping quarters must be designated for males and females with appropriate leadership. Appropriate modest sleeping attire must be worn. Parental notification and approval is needed for all sleep-over’s. Note: Signed permission slips must be obtained from the parents of all junior high students and younger. Volunteers should check with parents and use good judgment regarding movies, etc. Tools like screenit.com and pluggedin.com are recommended in addition to careful previewing. Personal Conduct I understand the bathroom policies and the “always two approved, unrelated adults rule”. I understand that ministry leaders need to know if I am going to be absent or unable to serve, I will talk to them or call them beforehand. I understand that I am expected to treat others as Jesus would treat them if He were in my place. We never spank or physically strike a student and we never speak harshly or shamefully. I understand that I am responsible for attending a worship service each week. My commitment to serving at BHBC will not replace my own worship and learning time. I understand there is to be no tickling, roughhousing, or lying on the floor with students. I understand I must attend ministry specific orientations and trainings (ie. B.Kids Huddles). I understand what is expected of me from this agreement. I am committed to doing my best to serve. Any sexual contact or sexualized behavior with a minor is a betrayal of sacred trust and is an exploitation of power which violates those who are vulnerable and absolutely will not be tolerated. BHBC is committed to investigate any and all allegations of misconduct either independently or in cooperation with a formal investigation that may include legal authorities. The alleged perpetrator will be asked to stop all ministry involvement throughout the time of the investigation until a decision is made.Name* First Last Signature (Child Protection Plan)*Statement of BeliefsPlease review the statement of belief at https://bhbconline.org/what-we-believe/ & additional belief statements herein. I HAVE READ, UNDERSTAND, AND AGREE TO ABIDE BY THE RULES, POLICIES, GUIDELINES CONTAINED AND THE STATEMENT OF BELIEF ON THE WEBSITE AND HEREIN. FURTHER, I GIVE BLYTHEFIELD HILLS BAPTIST CHURCH PERMISSION TO REQUEST CRIMINAL RECORDS AS NECESSARY.Name* First Last Signature (Statement of Beliefs)* This iframe contains the logic required to handle Ajax powered Gravity Forms.