Catholic Pro Life Community
Screening Form

Welcome to the Online Screening Form Program. The information you submit is private and secure. The data will only be sent to the Safety Director, and the Social Security Number is encrypted. The Safety Director for the Catholic Pro-Life Community in Dallas is . Fax number is: 972-267-5433

Instructions:
  1. Fill out the form.
  2. Click on the "Submit" button.
  3. The last page will be displayed.
  4. Print the last page, sign it, and send it to the Safety Director.

Please note that:
   An * shows required fields.
   Phone numbers can be entered in any of the following formats:
      ddd-ddd-dddd   ddd.ddd.dddd   ddd ddd dddd
      (ddd) ddd-dddd   dddddddddd

This form is to be completed for all applicants for any position (volunteer or compensated). This is not an employment application. Persons seeking employment will be required to provide additional information. This process is used to help the church provide a safe and secure environment for children, youth and adults who participate in our program and use our facilities.

Volunteer means any unpaid person engaged in or involved in a Diocesan activity, and who is entrusted with the care and supervision of children, and/or persons engaged or involved in ministry who have regular individual contact with the elderly or disabled. When you submit this form, it will be sent to the appropriate person. A release page will be displayed that you can print out, sign, and send to the church office.

Personal

First Name *
Middle Name
Last Name *
Nickname Example: Susie for Susan
Have you ever used a different first or last name?
If so, please enter those names:		 Example: maiden name
Street Address *
City *
State *
ZIP *
E-mail
Home Phone *
Employer
Work Phone
Cell Phone
Place of Birth (City, State)

Emergency Contact Information

Name
Phone

What type of ministry work do you prefer?
One or more items can be selected or deselected from the following list by holding down the Ctrl key and clicking the left mouse key.



Select the Parish in which you are registered or active.


Are you currently certified for Safe environment in your Parish? If not, you can skip the next question. if so, please select the correct entry in the next question and ask your Parish to send a letter of certification to the Safe Environment Manager.

Select the Parish that has certified you (background check and training).


Are you a registered member of the parish?
No Yes     Active since    Month    Day    Year   2 or 4 digit year


List all other churches you have attended or been involved with during the last five years:
Church Address Involvement From To


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


List three personal references you have known three years or more. (not former employers or members of your immediate family)

Reference 1

Name *
Street Address *
City *
State *
ZIP *
Home Phone At least one phone number is required for each reference (Home, Cell or Work).
Cell Phone
Work Phone
E-mail

Reference 2

Name *
Street Address *
City *
State *
ZIP *
Home Phone
Cell Phone
Work Phone
E-mail

Reference 3

Name *
Street Address *
City *
State *
ZIP *
Home Phone
Cell Phone
Work Phone
E-mail

In the next field, list your City, State, County and dates of residence for the past five years
City, State, County, Dates

Catholic Pro Life Community

Because the Catholic Pro Life Community of Dallas 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 all reasonable precautions to protect your privacy.

Are you presently abusing alcohol or using any illegal drugs?
Yes No
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 any criminal offense?
Yes No

Answering yes to these questions will not automatically exclude you for volunteering. The following lines are for any explanations or details that you would like to include for yes answers above.


Volunteer/Applicant Release Statement
Read Carefully!

· The information contained in this application is true and correct to the best of my knowledge.
· I understand that all criminal background checks will be treated as confidential.

· I understand and authorize the access to any and all information and records relating to my criminal history or criminal offenses committed or alleged, arrests, alleged criminal acts and criminal offenses committed.

· I understand and authorize any references, or any other person or organization, whether or not identified in this application, to give any information (including opinions) regarding my character and fitness for service.

· I hereby release any reference contact, whether identified or not in this application, and waive any and all claims, liability for damages of whatever kind or nature which may at any time result to me, my heirs/family, on account of compliance with this authorization, excepting only the communication of knowingly false information.

· I am aware that background checks may be updated periodically.

· If a disqualifying offense is found on a criminal background check, there is an appeal process in the Safe Environment Program. I understand that this process allows me to verify information and correct any errors.

· I intend this to be a legally binding release, which I have read and understand. I understand that I may consult with an attorney before signing this document. A facsimile or photocopy of this authorization shall be as valid as the original.

· I HAVE CAREFULLY READ THIS RELEASE AND KNOW THE CONTENTS. I SIGN THIS RELEASE AS MY OWN FREE ACT.


Date of Birth *    Month    Day    Year   2 or 4 digit year

Social Security Number (Last 4 digits only)  

Driver License Number *   (Enter your ID# if you do not have a DL.)

Driver License State *  



Signature___________________________________

Date: 03/26/2023