Screening Form

Catholic Charities, Diocese of Camden, Inc.

Program/Department _____________________________  City___________________

Or Facility

This form is to be completed by all applicants for all volunteer and intern positions.  This is not an employment application.  Persons seeking employment will be required to provide additional information.  This process is used to help Catholic Charities provide a safe and secure environment for children, youth and adults who participate in our programs and use our facilities.

Personal Information

Name___________________________________________________________________

             Last                                                 First                                       Middle

Address_________________________________________________________________

                                                                                    City                  State              Zip

Home Phone (      )___________________________ Work Phone (      )______________   

Emergency Contact Name______________________ Phone (     )___________________         

Employer______________________________  Address_________________________ 

Phone (    )______________________________

Are you a registered member of a Diocesan Parish?   Yes   No  Since_______________

Name of Parish_____________________________  City_________________________

List all other churches you have attended or been involved with during the last five years:

Church                   Address                              Involvement                   Dates

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

List any skills, talents, education., training or experience , including licensure or certification that qualifies you for the position you are seeking: 

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

List three personal references you have known three or more years (not family members):

1. Name __________________________________

     Address ___________________________________   Phone(H)__________________

     City____________________ State_____ Zip______   Phone (W)_________________

2.  Name __________________________________

       Address ___________________________________  Phone (H) ________________

        City _________________ State _____ Zip ______   Phone (W) ________________

3.  Name ___________________________________

       Address ____________________________________Phone (H) ________________

       City __________________ State _____ Zip _______ Phone (W) _______________

List your City, County, State and dates of residence for the past five years:

City                                     County                                    State                      Dates

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Because Catholic Charities, Diocese of Camden, Inc. cares for our children, youth and adults and desires to protect them, we ask you to please answer the following questions.  We understand the following questions are personal and we will take reasonable precautions to protect your privacy.

Social Security Number ________________  Date of Birth _______________________

Drivers License #________________________________  State issued______________

Have you ever been convicted of, pleaded guilty or no contest to, placed on probation for, given probation, given community supervision or given deferred adjudication for a crime or are you now under charges for a criminal offense?      YES___   NO___

Answering yes to these questions will not automatically exclude you from volunteering. The following lines are for any explanation or details you would like to include.

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Applicant’s Signature ____________________________________  Date_____________

CATHOLIC CHARITIES, DIOCESE OF CAMDEN, INC.  USE ONLY

Interviewed by: _________________________________________ Date_____________

Reference Check by: _____________________________________ Date_____________

Reference Check by: _____________________________________ Date ____________

Criminal Background Check by: ___________________________  Date_____________

 Clear ________                 Not Clear _________