This survey is to be completed by all those desiring a ministry position involving the supervision or custody of minors. It is being used to help the church provide a safe and secure environment for those children/youth who participate in our programs and use our facilities.
All information is held strictly confidential by the Child Protection Team.
I, _____________________________ hereby authorize the Child Protection Team of Salem
Baptist Church to make an independent investigation of my background, references, character,
past employment, education, criminal or police records including those by both public and
private organizations and all public records for the purpose of confirming the information
contained on my application or volunteer form(s), and/or obtaining other information which may
be material to my qualifications for employment or as a volunteer now and, if applicable, during
the tenure of my employment or as a volunteer with Salem Baptist Church.
I release Salem Baptist Church and any person or entity which provides information pursuant to
this authorization, from any and all liabilities, claim or lawsuits in regards to the information
obtained from any and all of the above referenced sources used.
The following is my true and complete legal name and all information is true and correct to the
best of my knowledge.
PLEASE FILL OUT THE FOLLOWING INFORMATION REQUESTED
Biblical truth and a family of worshipers for Dobson, Mount Airy, Elkin, Pilot Mountain, and the Surry County area.
430 Rockford Road Dobson, NC 27017 336-374-4419