Site Facilitator Application

Name*

First Last

Email*

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Gender*

Female

Male

Birthdate*

If at the above address less than five years, please list previous address.*

Please list all other cities and states in which you have lived as an adult:*

Language Fluency (Check all that apply)*

Employment History

(List present or most recent employer first.)

Name of Company #1*

Address*

Street Address Address Line 2 City State ZIP Code

Position Held*

Supervisor Name and Phone Number*

Reason for Leaving*

Duties*

Name of Company #2*

Address*

Street Address Address Line 2 City State ZIP Code

Position Held*

Supervisor Name and Phone Number*

Duties*

Reason for Leaving*

Name of Company #3*

Address*

Street Address Address Line 2 City State ZIP Code

Position Held*

Supervisor Name and Phone Number*

Duties*

Reason for Leaving*

BACKGROUND INFORMATION

Are you legally eligible for employment in the US?*

*Proof of citizenship or immigration status will be required upon employment.

Yes

No

Have you ever been the subject of a civil lawsuit involving sexual misconduct, sexual harassment, sexual abuse or other immoral behavior or conduct, involving adults or children? Have you ever been the subject of an investigation or allegation of sexual misconduct, sexual abuse or sexual harassment involving adults or children?*

Yes

No

Contact for notification in case of emergency*

Phone number and relationship to you*

If hired, when would you be available?*

Are there any days/hours you would not be available to work?*

Have you previously worked for us?*

(If yes, give dates)

Do you have any friends or relatives currently working for us?*

(If yes, please list)

Who referred you to us or how did you hear about us?*

Do you have any other skills you wish to mention?*

CHURCH ACTIVITY

Name of church where you are currently a member.*

Do you profess Jesus to be your Lord and Savior?*

Yes

No

Unsure

If you are a volunteer of Avenue941, how long have you been volunteering?*

If you have attended a different church in the past 5 years, please list it below. Provide the name and years attended*

Contact Person and Phone Number*

REFERENCES (Please include complete address, city, state, zip code)

** One reference must be a person of the opposite sex, one a family member, and the rest non-family members.

PERSONAL REFERENCE*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Email*

Phone*

PROFESSIONAL/CIVIC REFERENCE*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Email*

Phone*

FAMILY MEMBER REFERENCE*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Email*

Phone*

STATEMENT OF FAITH

Avenue 941 staff and board directors must affirm our Statement of Faith and try to live out godly character with the help of the Holy Spirit, their community and the Church. With that understanding, they agree to the Statement of Faith and live out these claims to the best of their ability as entrusted members of the Avenue 941 mission that are bringing hope to a lost generation. •We believe the Bible to be the inspired, the only infallible, authoritative Word of God. •We believe that there is one God, eternally existent in three persons: Father, Son and Holy Spirit. •We believe in the deity of our Lord Jesus Christ, in His virgin birth, in His sinless life, in His miracles, in His atoning death through His shed blood on the cross, in His bodily resurrection, in His ascension to the right hand of the Father, and in His personal return in power and glory and that He is the only way to the Father; He is the way, the truth and the life. •We believe that for the salvation of lost and sinful people, rebirth by the Holy Spirit is absolutely essential. •We believe in the present ministry of the Holy Spirit by whom followers of Christ are able to walk out a godly life. •We believe in the resurrection of both the saved and the lost; the saved to the resurrection of life (Heaven) and the lost to the resurrection of death (Hell) for eternity. •We believe in the spiritual unity of believers in Christ, that is the Church.

I affirm the above Statement of Faith.*

Yes

No

If no, please state below your reason why.

APPLICANT STATEMENT

As a site facilitator with Avenue941, you are asked to agree to the following guidelines: Make a commitment for at least ONE school-year (approximately 24 weeks). Read and utilize the resources in your Site Facilitator Manual, and attend all trainings. Be dedicated and dependable in maintaining a weekly relationship with the students at your site. To understand and accept that Avenue941 is a faith-based program and materials presented will reflect this foundation. Avenue941 may use your photograph and/or video material in its promotional materials. Authorize Avenue941 to obtain a consumer (criminal history) report on you. This consumer report may contain negative information about your background. This authorization, in original or copy form shall be valid for this and any future consumer report that may be requested by Avenue941. To understand that Avenue941 has a policy of ZERO TOLERANCE FOR ABUSE and takes all allegations of abuse seriously. To understand that Avenue941 cooperates fully with the authorities to investigate all cases of alleged abuse. Abuse of any kind is grounds for immediate dismissal from my position and possible criminal charges. The information in this application is correct to the best of my knowledge. I agree to the aforementioned guidelines. I authorize any references listed in this application to give you any information that they may have regarding my character and fitness for working with youth. I release all such references from any liability for furnishing such evaluation to you, provided they do so in good faith without malice. I authorize Avenue941 to conduct inquiries with appropriate agencies and references to confirm my eligibility to participate as a site facilitator. I understand and agree that it is critical to the mission and ministry of Avenue941 that all staff, teachers and volunteers conform to the highest standards of safety, interpersonal conduct, and sexual morality. I affirm that I will strictly comply with Avenue941's policies and procedures, including those concerning child safety and protection, sexual abuse and misconduct, and interpersonal relationships. I understand and agree that failure by me to abide by such policies and procedures may result in my immediate dismissal. I HAVE CAREFULLY READ, UNDERSTAND AND AGREE TO THE FOREGOING "APPLICANT STATEMENT" AND FURTHER UNDERSTAND AND AGREE THAT A COPY OF THIS APPLICATION SHALL BE AS VALID AS THE ORIGINAL.

Signature*

Today's Date*

Site Facilitator Application

Site Facilitator Application