General Info
First Name
Last Name Please provide a valid value.
Middle Initial Please provide a valid value.
Email
Name For Name Tag
Date of Birth Please provide a valid value.
Gender Male Female
When did you start attending Crossroads?
Site/Service Time where you attend
Street Address Please provide a valid value.
City Please provide a valid value.
State Please provide a valid value.
Zip Please provide a valid value.
Cell Phone Please provide a valid value.
Home Phone Please provide a valid value.
School
School
Grade
About You

Because you will be a role model, we need to know more about you.

Please answer the following questions.

How would you define your spiritual life? Pick as many as you like.
Searching for answers.
I have received Jesus.
Focusing on obedience—I’ve quit negotiating with God.
I’m actively replicating my faith in others.
Please Explain
Why do you want to serve?
Any special talents, abilities, skills or experiences that may be helpful? (Juggling, fire eating, acting, or making weird noises with your armpit count.) Please provide a valid value.
Serving Opportunities
What is your availability?
During the Week
Weekend Services
Weekend Site/Service Time
What age kids do you prefer to serve with?
1 - 2 years old
3-year olds - Pre-K
Kinder - 5th Grade
Personal References

List two adults you have known for at least one year, who are not related to you and have a definite knowledge of your character and ability to work with kids (e.g. pastor, close friend, and/or teacher)

#### First Reference

Name
Length of time known
Home Phone
Mobile Phone
Work Phone
Email
Nature of Association
Occupation

#### Second Reference

Name
Length of time known
Home Phone
Mobile Phone
Work Phone
Email
Nature of Association
Occupation
Parent/Guardian Commitment
Last Name
First Name
Home Phone
Mobile Phone
Email
Parent/Guardian Consent Yes No
Date
Student Agreement Yes No
Date