Adult Worker Registration

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10318 100 Ave NW,
Edmonton, AB T5J 0A2

(780) 430-3694

Join us as an Adult Worker for 2024

Please note that after completing your application you will be expected to complete mandatory Adult Worker training, as well it will be necessary to provide a negative Vulnerable Sector Check. Once complete you may be chosen as an Adult Worker at the discretion of the Executive Officer and DeMolay Canada.

Adult Worker Registration 2024

Step 1 of 4

25%

Section 1: Personal Information

Your Name (As it appears on your driver's license)(Required)

First Middle Last

Jurisdiction(Required)

Chapter Name:

Your Address(Required)

Street Address Address Line 2 City Province Postal Code

Gender(Required)

Male

Female

Birth Date(Required)

MM slash DD slash YYYY

Your Email Address(Required)

Email Address Confirm Email Address

Your Phone(Required)

Section 2: Profile Information

Personal Profile

Marital Status and name of Spouse, if applicable:

Personal Profile

Prior addresses for the last 5 years; length of time at each address:

Personal Profile(Required)

Have you ever worked as an Adult with any other Youth Group(s)? If so, please list and describe.

Yes

Explanation

Masonic Membership Profile

Please tell us about your Masonic Membership (if any)

Senior DeMolay

Mason

Scottish Rite

York Rite

Shrine

Order of the Eastern Star

Masonic Membership Profile

Senior DeMolay - Name of Chapter & Location

Masonic Membership Profile

Mason - Lodge Name, Number, & Jurisdiction

Employment Profile(Required)

What is your occupation?

Employment Profile(Required)

Name & address of current employer?

Educational Profile(Required)

What are the names, locations and dates of any high school you attended?

Educational Profile

What are the names, locations and dates of any colleges or universities you attended?

Driver's Profile(Required)

Have you ever been denied a license to operate a motor vehicle? If YES, please explain:

Yes

Explanation

Has your driver’s license ever been suspended or revoked within the last 10 years? If YES, please explain:(Required)

Has your driver’s license ever been suspended or revoked within the last 10 years? If YES, please explain:

Yes

Explanation

As a motor vehicle operator, have you ever been in any motor vehicle accidents involving fatalities, no matter when, whether at fault or not? If YES, please explain:(Required)

As a motor vehicle operator, have you ever been in any motor vehicle accidents involving fatalities, no matter when, whether at fault or not? If YES, please explain:

Yes

Explanation

As a motor vehicle operator, have you ever been in any motor vehicle accidents involving personal injury in the last 5 years, whether at fault or not? If YES, please explain:(Required)

As a motor vehicle operator, have you ever been in any motor vehicle accidents involving personal injury in the last 5 years, whether at fault or not? If YES, please explain:

Yes

Explanation

Have you ever been charged, arrested or received any tickets for driving under the influence of alcohol or drugs, drunk driving, reckless driving, careless driving, or speeding no matter when? If YES, please explain:(Required)

Yes

Explanation

Have you ever been accused, arrested, charged, or convicted of any type of crime? If YES, please explain:(Required)

Have you ever been accused, arrested, charged, or convicted of any type of crime? If YES, please explain:

Yes

Explanation

Have you ever been accused, arrested, charged, or convicted for the possession, use or transfer of alcohol? If YES, please explain:(Required)

Have you ever been accused, arrested, charged, or convicted for the possession, use or transfer of alcohol? If YES, please explain:

Yes

Explanation

Have you ever been accused, arrested, charged, or convicted for the possession, use or transfer of illegal drugs? If YES, please explain:(Required)

Have you ever been accused, arrested, charged, or convicted for the possession, use or transfer of illegal drugs? If YES, please explain:

Yes

Explanation

Have you ever been accused, arrested, charged, or convicted for crimes in which the alleged victim or accomplice was a minor? If YES, please explain:(Required)

Have you ever been accused, arrested, charged, or convicted for crimes in which the alleged victim or accomplice was a minor? If YES, please explain:

Yes

Explanation

Have you ever been accused, arrested, charged, or convicted for activities in which you allegedly physically or sexually abused anyone, male or female, or allegedly condoned such abuse by others? If YES, please explain:(Required)

Yes

Explanation

Have you ever been accused, arrested, charged, or convicted for Activities in which you allegedly were involved in the creation, possession, use or transfer of pornographic materials? If YES, please explain:(Required)

Yes

Explanation

Personal Health Profile:(Required)

Do you have any health limitations or health considerations that would limit your role as a “DeMolay Adult Worker?”. If YES, please explain:

Yes

Explanation

Have you used any illegal drugs, or been treated or hospitalized for drug abuse in the last 10 years? If YES, please explain:(Required)

Have you used any illegal drugs, or been treated or hospitalized for drug abuse in the last 10 years? If YES, please explain:

Yes

Explanation

Have you used any alcohol excessively or been treated or hospitalized for use of alcohol in the last 10 years? If YES, please explain:(Required)

Have you used any alcohol excessively or been treated or hospitalized for use of alcohol in the last 10 years? If YES, please explain:

Yes

Explanation

Has any adverse action been taken against you by any YOUTH organizations, school, church, or day care center, while you were an employee or volunteer for such organization or entity? If YES, please explain:(Required)

Yes

Explanation

To the best of your knowledge and belief are there any facts or circumstances involving you or in your background that would call into question you being entrusted with the supervision, guidance and care of young people? If YES, please explain:(Required)

Yes

Explanation

Has any adverse action been taken against you by any professional association, philanthropic, provincial or federal licensing bureau or academic institution, while you were an employee or volunteer for organization or entity? If YES, please explain:(Required)

Yes

Explanation

References

List three people who have known you for at least 5 years who we may contact if we need more information about you.

Reference 1 Name(Required)

Reference 1 Name

Reference 1 Relationship(Required)

Reference 1 Relationship

Reference 1 Email(Required)

Reference 1 Email

Reference 1 Phone Number(Required)

Reference 1 Phone Number

Reference 2 Name(Required)

Reference 2 Name

Reference 2 Relationship(Required)

Reference 2 Relationship

Reference 2 Email(Required)

Reference 2 Email

Reference 2 Phone Number(Required)

Reference 2 Phone Number

Reference 3 Name(Required)

Reference 3 Name

Reference 3 Relationship(Required)

Reference 3 Relationship

Reference 3 Email(Required)

Reference 3 Email

Reference 3 Phone Number(Required)

Reference 3 Phone Number

Section 3: Standards of Service

I understand that as a DeMolay Adult Worker, I am responsible for being a role model.(Required)

Yes

I understand that I am to follow the Youth Protection and Risk Management rules and procedures at all times.(Required)

Yes

I understand that I am to report all violations of DeMolay procedure to my Council Chairman or Executive Officer whether or not I am personally involved or have observed them.(Required)

Yes

I understand that proper supervision is required for all DeMolay functions.(Required)

Yes

I understand that the use of drugs or alcohol at DeMolay functions will not be tolerated and I will report any violations of this policy immediately.(Required)

Yes

I further authorize DeMolay Canada to verify this information and to satisfy itself that I should be trusted to work with young people.(Required)

Yes

I understand that I must provide an up to date (completed no more than two years from the date of this application) Vulnerable Sector Check or equivalent background check with this application.(Required)

Yes

I acknowledge that my service as an Adult Worker is at the complete and sole discretion of the Executive Officer and DeMolay Canada and that I may be removed or asked not to continue at any time with or without cause.(Required)

Yes

I understand that in addition to the final rulings and directives of the Officers of DeMolay Canada and/or the Board of Directors, that I am governed by the Rules & Regulations and Bylaws of DeMolay Canada and the bylaws of its subordinate organizations.(Required)

Yes

I understand and grant to DeMolay Canada, their representatives, and/or assigns, the right and permission to copyright and use, re-use, and publish, photographic images of me or in which I may be included, in whole or in part, or composite in character or form, without restriction as to changes or alterations for any other legal purpose. I hereby waive any right that I may have to inspect or approve the finished product or products or the copy or printed matter that may be used in connection therewith or the use to which it may be applied.(Required)

Yes

Acknowledgement

I am aware that one purpose of this form is to obtain my permission to allow a report to be obtained on me in the course of consideration for employment or volunteer purposes: criminal records, education, employment, or driver licenses records may be obtained. In connection with this request, I authorize all corporations, former employers, educational institutions, law enforcement agencies, city, province, county, and federal courts, military services, and persons to release information they may have about me to the person or company with which this form has been filed, or their agent. This releases the aforesaid parties from any liability and responsibility for collecting the above information. I release, hold harmless, and agree to indemnify DeMolay Canada, its chapters, advisory councils, and all other DeMolay bodies, organizations, and sponsoring organizations and their officers, employees, agents, and volunteers from any and all liability to me in connection with their good faith use, on behalf of DeMolay, of any information provided as a result of, or in connection with, this profile, and I similarly release, hold harmless, and agree to indemnify such organizations and individuals from any and all liability to me in connection with their good faith efforts to gather information about me as a result of, or in connection with, this profile. I promise that in my service as a DeMolay Adult Worker, I will bear true allegiance to DeMolay Canada and its Officers, and to the Executive Officer in this Jurisdiction, and I will obey their directives, the Bylaws, Rules and Regulations of DeMolay Canada, and the laws of my city, province, and nation. In signing this Profile, I certify that the information provided herein is true, complete and accurate. I promise to immediately notify the Executive Officer in this jurisdiction of any changes in the information supplied above.

Signature(Required)

By signing below you acknowledge the answers you have provided to the previous questions are complete and accurate representation of the relevant facts, and no information whether deliberate or otherwise has been omitted.

The Road Begins Here

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Adult Worker Registration

Resources Links

Contact Info

Join us as an Adult Worker for 2024

Section 1: Personal Information

Section 2: Profile Information

References

Section 3: Standards of Service

Acknowledgement

The Road Begins Here

Allegiance Statement

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