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Program for which you are volunteering:
Davidson United Methodist Church – Davidson, NC

Screening Form for Working with Children or Youth
All applicants for positions involving the supervision or custody of children or youth must complete this
screening form. Davidson United Methodist Church uses this form in order to help provide a safe and
secure environment for children and youth who participate in its programs.

Complete requested information, sign, and return to:
Davidson United Methodist Church, Attn: Pat Benfield, PO Box 718, Davidson, NC 28036

Personal
Last Name:

First Name:

Middle/Name at Birth:

Maiden Name:

Names previously used (i.e., previous marriages):
Dates used:
Nickname(s):

Dates used:

Date of birth:
Marital Status:

Social Security Number (required):

O Single

O Separated

O Married

O Divorced

Title used (i.e., “Dr.”):
Present address:

Attach a copy of your
driver’s license or other
photographic identification.
_

City:

County:

State:

Zip:

Phone (H):