Heartland Church of Sun Prairie - One to One Application

One to One Care Giver Application

First Name

Last Name

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Phone Number

Email

Birthdate

Gender

Thanks for your interest in this ministry! Please describe why you are interested in becoming a One to One Caregiver:

What spiritual gifts or strengths do you believe God has given you that would help you serve effectively as a One to One Caregiver?

In what ways do you think you would benefit personally from your training and service as a One to One Caregiver?

Based on your current understanding of what it means to be a One to One Caregiver, what could be challenging aspects of this role for you?

We ask that serving as a Care Giver is a two-year commitment. This includes the training, regular visits with your care receiver (weekly or a mutually agreed-upon frequency) and monthly small group peer supervision. Are you able to commit to this?

Yes

No

Please provide two references (non-family):

First Name

Last Name

Relationship

Email

Phone Number

First Name

Last Name

Relationship

Email

Phone Number

Many caregivers have been made stronger in a caregiving ministry through the care they themselves have received, including care from mental health professionals. We affirm the work of mental health professionals, who have helped many individuals to experience growth and healing. Have you ever received treatment for any emotional or psychiatric support?

Yes

No

If yes, someone from the One to One Ministry will speak with you about this so that the team may better understand its significance in your life and ministry.

Have you ever been charged with a crime?

Yes

No

If yes, explain in detail. Someone from the One to One Ministry will speak with you about this so that the team may better understand its significance in your life and ministry.

Please read below:
I attest that the information I have provided in this application is true and complete to the best of my knowledge. I give permission for the One to One Ministry, if it deems necessary, to call my references, secure a police background check on me, and consult with the treating physician(s) or other mental health professional regarding the nature of any treatment I have received for emotional or psychiatric problems.

In addition, I understand that Heartland Church has the right to decide through prayer and collaboration between elders and staff whether to continue or discontinue my application process and/or decide if I am to become a One to One Caregiver at any time.

Yes

No

One to One Care Giver Application

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