Background Inquiry Form

In order to provide for everyone’s safety, we need to ask the following questions. This form applies to all who serve in a leadership role with both adults and youth. Your answers will remain confidential.

Has anyone ever brought or threatened to bring a civil or criminal claim against you for physical or sexual abuse, neglect or sexual harassment?	:	yes no
In terms of employment, have you ever been let go, resigned or been reprimanded due to allegations of physical or sexual abuse or sexual harassment by you?	:	yes no
Have you ever been reprimanded as an adult student for harassment of another individual or other inappropriate behavior with another individual?	:	yes no
Have you ever been charged, arrested or convicted of a felony or misdemeanor?	:	yes no
Is there anything in your past that might come up as a questionable issue?	:	yes no
If you answered yes to any of the questions above, please let us know what state each incident happened and explain the situation.	:
Signature: By checking this box, I certify that I am the person listed on this form.	:
I give New Heights Church and its representatives the authority to verify the information on this application, which may include contacting references and appropriate government agencies.	:	yes no
First Name	:
Last Name	:
Date	:	1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Contact Phone Number	: