2XSALT, Inc.
Charlotte, North Carolina

Employee and Volunteer Ministry Application Form

This application form is to be completed by all employees and those desiring a ministry position involving the supervision or custody of children and/or youth. It is being used to help the ministry provide a safe and secure environment for those children and youth who participate in our programs and use our facilities.
Name     
 Last First Middle 
Date (mm/dd/yyyy)

Address         
  Street  City  State  Zip 
Email Address:
Home Phone Work Phone
Occupation Place of Employment
How long at this address? If less than five years, give previous address and number of years:
Years Address

Affiliated with 2XSALT since

List (names and addresses) other ministries you have been affiliated with during the last five (5) years.


What leadership / volunteer experience have you had with children / youth? (Be specific, where possible included dates and place if not at 2XSALT.)


Please list any other 2XSALT ministries in which you are involved.



Social Security Number Birth Date (mm/dd/yyyy)

Driver’s License Number State

Have you ever been convicted of or pled guilty or nolo contendere (no contest) to traffic violation(s) in the last five (5) years?

If yes, please describe all convictions for the past five (5) years and any conviction resulting in the suspension of you license, whether or not within the past five (5) years.

Do you have any medical training or are you CPR certified?


Is there any health related reason that would keep you from effectively working with or cause any potential harm to children? If yes, please explain.


Personal References: (Must be over 18 years old and not related to you.)

1. Name

Address

Phone Relationship


2. Name

Address

Phone Relationship


3. Name

Address

Phone Relationship

The questions listed below are necessary in order to help ensure a safe and secure environment for our children and for the protection of our volunteer and/or paid staff. All information is held strictly confidential. Please answer these questions. If you have any concerns regarding the questions, please consult with the appropriate staff member:
  Yes No
Have you been convicted for the use or sale of drugs?
Have you been hospitalized or treated for alcohol or substance abuse?
Have you been arrested for a criminal offense excluding minor traffic violations?
Have you been arrested or convicted for any sexually related crimes?
Have you ever been denied participation in supervising youth activities in any organization?

Please explain any yes answers.



Applicant’s Statement

The information contained in this application is correct and complete to the best of my knowledge.  I authorize any references, ministries, or other organizations listed in this application to give you any information they may have (including employer’s opinions) regarding my character and fitness for working with children or youth and I hereby release all such references, ministries, or other organizations from liability for damages of whatever kind or nature that may result from furnishing such evaluations to you.  I waive any right 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 follow the Child and Youth Protection Policy and to refrain from inappropriate conduct in the performance of my services on behalf of the ministry.  I understand that any violation of this Code of Conduct or misrepresentation of information that I have provided may result in termination of employment or volunteer service with children/youth.
I have not been convicted of a child or youth sexual or physical abuse crime.  I am not currently involved in any allegation of abuse of a child or youth.
I authorize that a Criminal and Civil Records Check may be conducted on me and that any information which pertains to any record of convictions contained in police files or any criminal or civil file maintained on me, whether state or local, be released to the ministry. In so authorizing, I release any law enforcement agencies, 2XSALT, Inc. or those individuals receiving the results of the check from any and all liability resulting from such disclosure.
I acknowledge that I have read the 2XSALT Child and Youth Protection Policy and have received copies for my personal use.
I further state that I HAVE CAREFULLY READ THE FOREGOING RELEASE AND KNOW THE CONTENTS THEREOF AND I SIGN THIS RELEASE AS MY OWN FREE ACT IN EXCHANGE FOR THE OPPORTUNITY TO SERVE AS AN 2XSALT Volunteer. This is a legally binding agreement, which I have read and understand. I understand that the personal information will be held confidential by the professional ministry staff.

Applicant’s Signature Date (mm/dd/yyyy)

PERSONAL INTERVIEW SIGN-UP:
Days and time typically available

FOR MENTORING VOLUNTEERS ONLY

Please describe your personal Christian faith:

Special skills, talents or interests you have that might be helpful:

Who has been a mentor for you and how have they impacted your life?

Which days are you available to mentor?

  Yes No
Monday
Tuesday
Wednesday
Thursday

The Faith, Hope and Love Mentoring Program serves elementary aged children and operates out of two separate mentoring locations.  Please select your mentoring site preference:

Progressive Baptist Church:  1600 Clanton Rd. Charlotte, NC 28208.  Serving elementary school students.  Mentoring Monday – Thursdays from 5pm to 6pm.

St. Paul United Methodist Church:  2830 Dorchester Pl. Charlotte, NC 28209.  Serving elementary school students.  Mentoring Monday - Thursdays from 5pm to 6pm.

Volunteer Commitment:

I wish to serve as a volunteer with 2XSALT’s Faith, Hope and Love Mentoring Program or 2XSALT Leaders Club.  As a volunteer I commit to the following:

  • To adhere to 2XSALT Ministries, Inc. policies and procedures including the Child Protection Policy. 
  • To participate in mentor events which include training and community fellowship opportunities.
  • To meet my weekly time and duty commitments as a mentor or provide adequate notice so that alternate arrangements can be made.
  • The release of all pictures to 2XSALT Ministries, Inc. for use in newsletters and advertising, unless specifically notified otherwise by the volunteer.

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