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Background Check Information



The safety of the children entrusted to our care is our overriding concern. In addition, we are required by our church policies and our insurance company to obtain a Federal background check for anyone who works with, or chaperones children, at a church sponsored activity. We reserve the right to deny to anyone application for any reason and without explanation. The information is provided only to State or Federal law enforcement agencies for the purpose of obtaining a background check. The information we receive from them is given to the minimal number of people concerned (usually only our church secretary and Childrenís Ministry Director.) We hold this information in the strictest confidence and will not provide it to another party.


1. Please copy and past the information below onto a blank word document, then fill out completely.

2. Print and Mail to Dee Bainton at PO box 277, Black Diamond, WA 98010 or FAX to 360-886-8129. (This is a private FAX of our church secretary. It is not in a publically accessible area.)

3. You may leave the SSN and DLN blank. But you must call our church secretary-Dee Bainton (360-886-2587) with this information after mailing or faxing the other general information.

Applicantís Full Name: _______________________________________________

Alias / Maiden Name: _______________________________________________

Date of Birth: _____________________________________________________

Gender: _________________________________________________________

Address: _________________________________________________________

City/State/ZIP: ____________________________________________________

Phone Number: ____________________________________________________

Social Security Number: _____________________________________________

Driverís License Number: ________________________ State of issue: ________



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