FIRST PRESBYTERIAN CHURCH - CHILD AND YOUTH PROTECTION POLICY AND PROCEDURES

Updated May 14, 2018

 gfrFIRST PRESBYTERIAN CHURCH
URBANA, OH

CHILD AND YOUTH PROTECTION POLICY AND PROCEDURES

CONTENTS

POLICY STATEMENT        2

GENERAL PROCEDURES        2

OFF-SITE TRIPS & EVENTS        3

CODE OF CONDUCT        4

SCREENING        6

Staff        6

Volunteers        6

PRIVACY NOTICE        7

REPORTING        8

RESPONDING TO A KNOWN SEX OFFENDER IN CHURCH        9

TRAINING        10

GENERAL SOCIAL MEDIA POLICY        10

Social Media Communications        10

Social Media Code of Conduct        11

POLICY VIOLATIONS        11

SIGNING OF POLICY AND APPLICATION TO SERVE        11

TERMS & DEFINITIONS        11

ACKNOWLEDGEMENT OF RECEIPT OF THE FIRST PRESBYTERIAN CHURCH
CHILD AND YOUTH PROTECTION POLICY AND PROCEDURES
        13

APPLICATION AND BACKGROUND CHECK AUTHORIZATION        14

YOUTH PERMISSION AND RELEASE FORM        15

INCIDENT REPORT FORM        18


  1. POLICY STATEMENT

First Presbyterian Church (“FPC”) is committed to providing a church environment that is a safe place for children and youth and that will protect them from any abuse when they are involved in church-related activities.  FPC adopts these policies and procedures not only to maximize safety and prevent child abuse from occurring within its church community, but also to guide and protect volunteers and employees from unwarranted allegations of child abuse.

  1. GENERAL PROCEDURES

  1. Supervision: Two-Leader/Open-Door Policy
  1. Whenever possible, any adult who is present in a church sponsored activity for children or youth should be accompanied by another adult.  FPC employees and volunteers should not, during an FPC program, be alone with a single child where they cannot be observed by others.
  2. In order to avoid situations where an individual is alone in a room with children, all children’s and youth activities should be supervised by at least two adult leaders. Whenever possible, these adults should be unrelated.  The presence of two leaders is to protect children and youth against situations in which abuse might occur, and to protect leaders against false allegations of abuse or neglect.
  3. Classrooms, childcare rooms, and any area in which programs for children or youth are taking place may be visited without prior notice by church staff, parents, or other volunteer church workers.  No windows may ever be totally blocked so as to prevent visual observation into the classroom.
  4. In the event that two leaders cannot be present in the room, such that one leader is alone in a room with one or more children or youth, a door or half-door from the room must be left open.  The leader should not position himself or herself in the room such that other adults passing in the hallway cannot see him or her.
  5. Furthermore, at any counseling session with children or youth, the door or half-door of the room used must remain open for the entire session.  The session should be conducted at a time when others are nearby, even if they are not within listening distance.
  6. Each classroom for children and youth should ideally have a door with an observation window or a half- door, such that the upper half may be kept open.  If it does not, and two leaders are not present in the room, then the door must remain open at all times.
  1. Ratios. The recommended adult/volunteer-to-child/youth ratio, based on best practices, is 1:6, gender balance is recommended.  For overnight trips and in the nursery, the ratio is 1:4, although 1:6 is permissible.  Teacher/caregiver-to-child ratios are mandated by state childcare laws.
  2. Parental/Guardian Consent. Children and youth must obtain parental or guardian permission for involvement in church sponsored activities or programs that involve travel away from the church’s physical facilities.
  3. “Six Month” Rule for Volunteers. A volunteer must be a member of FPC, or have regularly attended FPC, for six months before working with youth or children.  This requirement does not apply to paid staff or volunteers involved in activities in which their own children are present.  The Christian Education Committee shall have the authority to waive this six-month rule upon request, where appropriate.
  4. Policy Review. The provisions of this Policy shall be reviewed annually by the Christian Education Committee by September 1 each year.  Any proposed changes to the Policy will be brought to the attention of the Personnel Committee for its input, if any, prior to any such changes by the Christian Education Committee becoming final.  The Christian Education Committee shall report periodically to the Session and recommend any changes deemed appropriate.
  1. OFF-SITE TRIPS & EVENTS

  1. Permission Forms. Youth Permission and Medical Release Forms must be completed, or on file, prior to all trips. The two-adult rule must be followed throughout the trip with any foreseeable exceptions clearly stated and approved in advance by the parent or guardian. The total number of adults on each trip will be adjusted according to the requirements of the planned activities. Under no circumstances may one adult alone take or accompany minors on an overnight outing.
  2. Ratios. The required adult to child/youth ratio for chaperones for any ministry with children or youth shall be 1:6. Gender balance is preferred.  For overnight trips, an adult to child/youth ratio for chaperones of 1:4 is preferred, although 1:6 is permissible.  Gender balance is required.
  3. Rooming Arrangements
  1. Rooming arrangements should provide for children and youth of the same sex to room together and adults of the same sex to room together.
  2. When possible, adults’ rooms shall be next to youth rooms and youth may be checked on during the night.
  3. Ordinarily, adults should not share rooms with children. An individual minor may share a room with an individual adult if the two are related (parent/child), or if written permission has been granted prior to the event by a parent or guardian (in such cases as Intergenerational Mission Trips).
  4. In situations where one large sleeping area is provided, two adults of the same sex shall accompany children or youth of the same sex.
  1. Medical
  1. Each child, youth, adult volunteer, and staff must submit a completed medical/insurance form.  Each minor’s forms must have a parent or guardian’s signature.
  2. Whenever possible, all activities with children and youth shall have a staff or volunteer adult leader with current-certification first aid/CPR training.
  3. Group leaders should have a copy of all medical forms for overnight or off-site events.  These forms will be kept on the event site for the duration of the event.
  4. First Aid supplies will be available on the event site.  All workers will be informed of the location of First Aid supplies/equipment and shall have access to information concerning specific medical conditions and concerns of participants.
  5. A written incident report will be completed in the case of any accident, medical emergency or injury.
  1. Driving Rules/Travel
  1. The recommended age for drivers of children and youth is over 21.  In situations where this is not possible, parent permission shall be obtained before the trip and vehicles shall travel together.
  2. When one vehicle is used for an event, the two-leader rule still applies unless parental permission is obtained prior to the trip.  When several vehicles are taken for an event and two leaders are not available for every vehicle, keeping the other vehicle in sight at regular intervals is an acceptable substitution for the two-leader rule.
  3. Travel arrangements for off-site events will be coordinated through the church.
  4. A valid driver’s license will be required.
  5. All vehicles should remain parked throughout the duration of the activity except for transporting children and obtaining supplies.
  6. Seat belts will be provided for all passengers. Children up to age 4 or less than 40 pounds be restrained in a child restraint system as required by law.
  1. CODE OF CONDUCT

  1. Staff and volunteers are required to adhere to the FPC Child And Youth Protection Policy And Procedures in all their interactions with children and youth.
  2. Staff and volunteers will respect children’s rights not to be touched in ways that make them feel uncomfortable or that disregard their right to say no.
  3. Staff and volunteers may not discipline children by use of physical punishment or by failing to provide the necessities of care.
  4. Physical restraint is used only in situations necessary to protect the child, other children, or staff from harm.
  5. While supervising children and youth participating in FPC programs, staff and volunteers should be with participants at all times except in private restroom areas.
  6. Restroom supervision:  Whenever possible, volunteers will make sure any restroom used is not occupied by any suspicious or unknown individual before allowing children and youth to use the facilities.  Always send children in pairs with a volunteer.  The staff or volunteer, will stand in the doorway while children are using the restroom.  This policy allows privacy for the children and protection for the staff or volunteer (not being alone with a child).   Staff and volunteers shall strongly encourage parents to take children to the restroom whenever possible.
  7. Diapering and potty training should be done primarily by staff members/paid caregivers.  
  8. Staff and volunteers should be alert to the physical and emotional state of children.  Any signs of injury or possible child abuse must be reported according to the FPC Child And Youth Protection Policy And Procedures.
  9. Staff and volunteers are discouraged from being alone with children or youth without parental permission.
  10. Under no circumstances should staff or volunteers release children to any adult or family member (including older siblings) other than those individuals identified by the child’s parent/guardian on the Youth Permission Form.
  11. Consuming, using, possessing, or being under the influence of alcohol or illegal drugs while working or volunteering with children or youth is prohibited.
  12. Being impaired by legally prescribed drugs while working or volunteering with children or youth is prohibited.
  13. Possessing or using concealed weapons or firearms while working or volunteering with children or youth is prohibited.
  14. Smoking or use of tobacco in the presence of children, youth, or parents while working or volunteering is prohibited.
  15. Profanity, inappropriate jokes and media, sharing intimate details of one’s personal life, and any kind of harassment in the presence of children, youth, or parents are prohibited.
  16. Staff and volunteers will be mindful of the content on any portable electronic device, social networking pages, or other electronic media that might be accessible to any children and youth.
  17. Staff and volunteer adult and youth leaders shall wear appropriate dress when volunteering with children and/or youth.
  18. Movies used in all church settings shall meet the voluntary movie rating system guidelines established by the Motion Picture Association of America for age-appropriate content.
  19. Staff and volunteers may not date or be romantically involved with program participants or church members who are younger than 18 years of age.
  20. Staff and volunteers are required to read, sign, and adhere to all policies related to identifying, documenting, and reporting child abuse and will attend training sessions on the subject.
  21. Staff and volunteers are required to report any concerns or suspicions regarding their observations of any individual’s interaction with a child. Except for concerns related to alleged or potential abuse, which require specific immediate reports, these concerns may be reported to the individual.  If the concerns are not alleviated by a change in the individual’s behavior, a second report must be made to the Minister or the Director of Christian Education.
  22. If it is necessary for an adult to take a child or youth home after an event, all staff and volunteers shall abide by safe driving laws when transporting children or youth. An effort should be made to contact the family and inform them of the situation before transporting the child or youth.  It is always advisable for leaders to give parents advance notice and full information regarding the event in which their child or youth will be participating.
  23. In the event that a one-on-one child/youth to adult scenario arises, i.e., unexpected transportation needs, confirmation mentoring, or otherwise, parent permission should be granted in writing or by phone when possible.  It is preferred to have mentors and confirmands meet in pairs or to meet in public places.
  1. SCREENING

  1. Staff

  1. Background Requirements. Applicants for full-time or part-time paid employment at FPC will be required to provide, complete or undergo the following:
  1. A Youth & Children’s Staff/Volunteer Worker Application which will include information regarding past employment and prior convictions for crimes;
  2. A specific statement that the individual has no prior conviction for child abuse or sexual misconduct; and
  3. A reference check covering, where possible, the two immediate past employers, or personal references unrelated to the applicant if no information can be obtained from past employers.
  4. Prior to hiring an applicant, FPC will obtain a criminal record report for that individual.  Every three years, FPC will perform national criminal database searches and national sex offender registry searches on existing employees, and each employee shall be required to execute any documents that FPC might request for such purpose.  Any individual who has lived outside Ohio in the last five years may be subject to additional county or state court search.
  5. Upon being hired, each new employee will be required to sign an acknowledgement that he or she has received a copy of the FPC Child & Youth Protection Policy, understands it and will comply with its terms.
  6. Each new employee will be provided orientation and training on child abuse, including its recognition and prevention, as well as on the terms and conditions of this policy.
  1. Any candidate for employment who has a past conviction of or pending proceeding addressing an allegation of child abuse or neglect cannot be employed by FPC. Conviction for any of the following will automatically disqualify an individual from employment: drug-related, pedophilic behavior, incest, rape, assaults, indecent exposure, pornography, sodomy or abuse of a minor.
  1. Volunteers

  1. Background Requirements. Volunteers working with youth or children of the church in any volunteer ministry, will be required to provide, complete or undergo the following:
  1. A Youth & Children’s Staff/Volunteer Worker Application which will include information regarding past employment and prior convictions for crimes. When a volunteer is employed or is a regular volunteer at a school within Champaign County or with an organization that requires a background check, a copy of their cleared background check will suffice. Additionally, a search of background check updates for state-licensed educators can be found at https://coreprodint.ode.state.oh.us/CORE2.3/ODE.CORE.EducatorProfile.UI/BackgroundCheckDisplay.aspx.
  2. A specific statement that the individual has no prior conviction for child abuse or sexual misconduct; and
  3. Prior to becoming a volunteer, FPC will obtain a background check for that individual.  Every three years, FPC will perform national criminal database searches and national sex offender registry searches on existing volunteers and each volunteer shall be required to execute any documents that FPC might request for such purpose. Any individual who has lived outside Ohio in the last five years may be subject to additional county or state court search.
  4. Each new volunteer, prior to beginning any volunteer role, will be required to sign an acknowledgement that he or she has received a copy of the FPC Child & Youth Protection Policy, understands it, and will comply with its terms.
  5. Each new volunteer will be provided orientation and training on child abuse, including its recognition and prevention, as well as on the terms and conditions of this policy.
  1. Any candidate for volunteer service who has a past conviction of or pending proceeding related to an allegation of child abuse or neglect MAY NOT work with children and youth at First Presbyterian Church. Refusal to complete the Volunteer Application process or a conviction for any of the following will automatically disqualify an individual from volunteer service with children and youth: child endangerment, corruption of a minor, contributing to the delinquency of a minor, drug-related activity, pedophilic behavior, incest, rape, assaults, indecent exposure, pornography, sodomy, or abuse of a minor.
  1. PRIVACY NOTICE

  1. Overview. This privacy notice discloses the privacy practices for First Presbyterian Church and/or http://ufpc.church. This privacy notice applies solely to information collected by First Presbyterian Church and/or its website. It will notify you of the following:
  1. What personally identifiable information is collected from you through First Presbyterian Church and/or its website, how it is used and with whom it may be shared.
  2. What choices are available to you regarding the use of your data.
  3. The security procedures in place to protect the misuse of your information.
  4. How you can correct any inaccuracies in the information.
  1. Information Collection, Use, and Sharing
  1. We are the sole owners of the information collected by First Presbyterian Church and/or its website. We only have access to/collect information that you voluntarily give us via email or other direct contact from you.  We will not sell or rent this information to anyone.
  2. We will use your information to respond to you, regarding the reason you contacted us.  We will not share your information with any third party outside of our organization, other than as necessary to fulfill your request, e.g. process secure, encrypted background checks.
  3. Unless you ask us not to, we may contact you via email in the future to tell you about upcoming ministry events, new volunteer opportunities, or changes to this privacy policy.
  1. Your Access to and Control Over Information
  1. You may opt out of any future contacts from us at any time. You can do the following at any time by contacting the church secretary at (937) 653-4225.
  1. See what data we have about you, if any.
  2. Change/correct any data we have about you.
  3. Have us delete any data we have about you.
  4. Express any concern you have about our use of your data.
  1. Security
  1. We will take reasonable steps to keep secure the personal information which we hold and to protect it from unauthorized disclosure and misuse. Any information on paper will be kept in a locked filing cabinet only accessible by the Minister and Administrative Assistant.
  2. Email is not a secure method of transmitting information, so we cannot accept responsibility  for the security of information you send to us by email.
  1. REPORTING

  1. The Ohio Revised Code section 2151.421 mandates that certain people are required to make a report to child protective services or law enforcement if they suspect that abuse is taking place. The law requires that you make a report if you believe that a reasonable person would also suspect abuse or neglect, given the same circumstances.
  2. ALL abuse or suspected abuse should be reported to the staff person in charge using the appropriate form. A report should be written and reviewed by the senior staff as to who will report and how it will be reported to the authorities.
  3. The following procedures will be followed when confronted with an abuse allegation or incident:
  1. Immediately ensure the safety of the child or youth.
  2. Report the event immediately to the Director of Christian Education or Head of Staff (minister), but do not leave the child alone while doing so.
  3. Make notes as appropriate as to what was seen or heard.
  4. Do not discuss the event with anyone other than those identified above.
  5. Do not confront the alleged perpetrator.
  6. Any employee or worker accused of abuse will be removed immediately from contact with children until an investigation by authorities is concluded. The results of the investigation will determine if the person is reinstated or released.
  7. The appropriate staff member (or his/her designee) will:
  1. Contact the appropriate civil and religious authorities.
  2. Complete the Incident Report Form
  3. Notify the child’s parent(s) or guardian(s)
  4. Notify the church’s legal counsel and insurance carrier
  5. Employees and volunteers of FPC are not at liberty to discuss matters with the media.  All media releases will be handled by the Head of Staff.
  6. Contact the appropriate authorities.
  1. Call 911 if you believe a child is in immediate danger of serious harm.
  2. Within Champaign County.
  1. Anyone may make a report of suspected child abuse or neglect to Champaign County Department of Job & Family Services (CCDJFS) by calling 937-484-1500.
  2. In non-emergency situations reports of suspected child abuse, neglect or dependency can be made by phone, in person, or in writing.
  3. After hours, Children’s Services can be accessed for emergencies by calling the Champaign County dispatch center at 937-653-3409 and asking for the on-call Children’s Services worker to be paged.
  1. Outside of Champaign County. The Ohio Department of Job and Family Services has launched 855-O-H-CHILD (855-642-4453), an automated telephone directory that will link callers directly to a child welfare or law enforcement office in their county.
  1. RESPONDING TO A KNOWN SEX OFFENDER IN CHURCH

  1. When the senior pastor, or any member of the church board, is informed that a registered sex offender is attending the church, the following steps will be taken to manage risk.
  2. These include the following:
  1. Obtain a record of the sex offender's prior criminal convictions by conducting a national criminal records check. The church must be fully informed regarding the sex offender's criminal background.
  2. If the sex offender is on probation, identify his or her probation officer and ascertain the conditions that have been imposed. In some cases, sex offenders are not even allowed to attend church. If the probation officer says that the offender is free to attend church, ask the officer if he or she would recommend that the offender be allowed to attend church, and if so, under what conditions. Obtain this information in writing, or, if that is not possible, make a detailed written account of the officer's response.
  3. Condition the sex offender's right to attend church services and activities on his or her signing a "conditional attendance agreement" that imposes the following conditions:
  1. The sex offender will not work with minors in any capacity in the church.
  2. The sex offender will not transport minors to or from church, or any church activity.
  3. The sex offender will not attend any youth or children's functions while on church property, except for those involving his or her own child or children, and only if in the presence of a chaperone (see below).
  4. The sex offender will always be in the presence of a designated chaperone while on church property. This includes religious services, educational classes, activities, and restroom breaks. The chaperone will meet the sex offender at the entrance of the church, and accompany the sex offender on church premises until returned to his or her vehicle.
  5. A single violation of these conditions will result in an immediate termination of the sex offender's privilege to attend the church.
  6. The conditional attendance agreement option will not be available unless the church's insurer is informed and confirms that coverage will not be affected.
  1. In some cases, exclusion of the offender from church is the only viable option. This option is advisable if
  1. for any reason the conditional attendance option is not feasible or enforceable; or
  2. the offender's crimes are so frequent or heinous that exclusion is the only appropriate option; or
  3. the offender’s victim(s) attends the church.
  1. It is often desirable to draft a short policy addressing the church's response to registered sex offenders attending the church, and have it adopted by the congregation during an annual or special business meeting. This would allow the membership to discuss this issue in a rational manner.
  2. Seek legal counsel in formulating the church's response.
  1. TRAINING

  1. First Presbyterian Church will provide annual training on this child protection policy to all children’s/youth ministry volunteers and employees and will strive to provide opportunities for additional training classes when new volunteers begin after our annual training has occurred. The training can only be administered by a member of the Christian Education Committee or the Pastor. All volunteers and staff are required to attend these training events.
  1. GENERAL SOCIAL MEDIA POLICY

No minister, employee, contractor, or volunteer of the General Assembly and its entities shall create or use a media site (Web, Facebook, YouTube, or similar) in the name of or purporting to represent the FPC without the explicit permission of the Session. When clergy or staff, acting in their capacity as a representative of the FPC, lead or coordinate a group activity using social media, each may use only official channels when they have been made available by the Session. These may include Web pages, Facebook, email, and similar means.

  1. Social Media Communications

  1. Persons who shall create public pages on behalf of the FPC are responsible to monitor communications and to assure that employees and volunteers do not have private (and possibly inappropriate) conversations with children and youth.
  2. Persons having Facebook privileges on behalf of the FPC entity shall treat unsolicited communication or “friending” from children or youth under age as an unauthorized text message. No reply may be given except to indicate by a posting that accepting a “friend” invitation by under-age children is a violation of the code of conduct.
  3. If a child or youth reveals abuse or inappropriate interactions with an adult, the person must report this information in the manner of any “suspected abuse.”

  1. Social Media Code of Conduct

Church Employees and volunteers who use any church social media platform shall apply this Social Networking Code of Conduct:

  1. Avoid both impropriety and the appearance of impropriety on all church social media platforms.
  2. Provide children, youth, and their parents with this Social Networking Code of Conduct.
  3. Encourage parents to play a role in monitoring their children’s and youth interactions with employees and volunteers.
  4. Continuously remind children and youth how to interact appropriately through social networking sites.
  5. Deny participation by individuals who repeatedly violate the code of conduct.
  1. POLICY VIOLATIONS

Any employee or child/youth volunteer that does not follow these policies will be notified of their actions. If the violation is considered to be major (as determined by the staff or committee) the person will be terminated from their position immediately. Pending an investigation and/or review he/she may be reinstated. Minor violations will be placed in the worker’s file. Multiple violations may result in termination.

  1. SIGNING OF POLICY AND APPLICATION TO SERVE

Each employee or child/youth volunteer shall acknowledge receipt and understanding of the First Presbyterian Church’s Child And Youth Protection Policy And Procedures and that services as an employee or volunteer at the First Presbyterian Church is dependent on strict adherence to these policies.

  1. TERMS & DEFINITIONS

Child abuse - An act committed by a parent, caregiver, or person in a position of trust (even though he or she may not care for the child on a daily basis) which is not accidental and which harms or threatens harm to a child’s physical or mental health or welfare.  Types of abuse may include physical abuse, including physical injury or threat of injury; physical neglect, such as failure to provide necessary care to a child; sexual abuse; mental abuse or neglect; emotional abuse; and spiritual abuse. Child abuse includes, but is not limited to:

Neglect of Basic Needs - A form of abuse. Denial of food, water, cleanliness, clothing, and sleep are not appropriate means of discipline.

Physical Abuse - Any physical force applied by an adult or older youth in a position of care or authority to a child, youth, or vulnerable adult. Physical force (hitting, spanking, shaking, shoving, etc.) is not to be used by leaders in our programs.

Sexual Abuse – Any sexual contact or sexual interaction between a child (under the age of eighteen years) and an adult; any use of a child for the sexual simulation of an adult, a third person, or the child; any risqué jokes, innuendo, unacceptable visual contact, unwelcome casual touch, unwelcome and inappropriate hugs and kisses, and sexually suggestive pictures between an adult and a child, as deemed inappropriate by any reasonable adult. Even if a child, youth, or vulnerable adult, out of ignorance, innocence, or fear does not resist, it is still abuse.

Emotional Abuse - Inappropriately belittling, hateful, or angry words and/or actions directed toward a child, youth, or vulnerable adult. Discipline by humiliation is also emotional abuse.

Spiritual Abuse- Using religious references to shame or by guilt to motivate a child into a particular action or behavior.

Employee – Any person who works for salary or wages at First Presbyterian Church (FPC)

Volunteer – Any person not employed by FPC who, at any time during the year, teaches, supervises, or helps with children and youth activities, or is in the presence of children or youth.  These activities include, but not limited to, Sunday School, Children’s Church, Nursery, Childcare, LOGOS, Summer Camps & Conferences, Children & Youth mission trips.

Leader – An adult designated by FPC or by a sponsoring organization to have responsibility for children and/or youth. The adult must be a minimum of 18 years of age. Leaders of overnight trips must be at least 21 years of age.  It is suggested that leaders be a minimum of four years older than the children or youth they are supervising.

Church Sponsored Activity - Includes any and all gatherings that arise from any worship, educational, childcare, fellowship, administrative, pastoral, mission or recreational event generated or organized by FPC, whether on-campus or off-campus.

Volunteer Ministry – Includes any church sponsored activity engaged in by a volunteer.

Child or Youth – Persons under 18 years old and considered a minor under the law. This term shall also include legally incompetent persons.


ACKNOWLEDGEMENT OF RECEIPT OF THE FIRST PRESBYTERIAN CHURCH
CHILD AND YOUTH PROTECTION POLICY AND PROCEDURES
        

I have been given a copy of the FIRST PRESBYTERIAN CHURCH CHILD AND YOUTH PROTECTION POLICY AND PROCEDURES and have read and understand this document.

Further, I understand that my services as an employee or volunteer at the First Presbyterian Church is dependent on my strict adherence to these policies.

Signature:

Date:


APPLICATION AND BACKGROUND CHECK AUTHORIZATION

(Note: You may complete this form online at http://ufpc.church/volunteer-registration)

First Name*:

Middle Name:

Last Name*:

Maiden or Alias Names Used:

Date of Birth (incl. year) *:

Social Security Number *:

Phone Number*:

Address *:

City /State/Zip*:

*Required solely for background screening purposes and will not be used for anything else.

I, ___________________, hereby authorize the First Presbyterian Church of Urbana, Ohio, to conduct a Background Check (consisting of a National Criminal Database Search and a National Sex Offender Registry Search) for the sole purpose of determining suitability for volunteering in activities designed for those under 18 years of age, or suitability for employment by First Presbyterian Church. I understand that the information provided by you and received from Clear Investigative Advantage will be filed in a locked cabinet and will only be accessible to the pastor and the administrative assistant.

Signature: ______________________________________________

*Upon completion of this form, please submit to Administrative Assistant Judy Brooks in the church office.


YOUTH PERMISSION AND RELEASE FORM

This form is required to be signed by a parent or guardian before youth attend any event outside of the church and is valid for one year unless otherwise specified by the parent or guardian.

YOUTH INFORMATION                                                                 EFFECTIVE DATE: __________________

Name _________________________________________________________         EXPIRATION DATE: _________________

Address:_______________________________________________________

School: ____________________________ Grade _________ Birth date __________

Youth Email _________________________ Youth Home Phone _______________ Youth Cell Phone ________________

PARENT/ GUARDIAN INFORMATION

Name _________________________________________________________ Relation ____________________________

Email _____________________________ Home Phone ______________________ Cell Phone _____________________

Name _________________________________________________________ Relation ____________________________

Email _____________________________ Home Phone ______________________ Cell Phone _____________________

ADDITIONAL EMERGENCY CONTACT

Name _________________________________________________________ Relation ____________________________

Email _____________________________ Home Phone _______________________ Cell Phone ____________________

PRIMARY CARE PHYSICIAN

Name: ____________________________ Practice: ___________________________ Phone: ______________________

Date of last Tetanus shot _________________________________

INSURANCE INFORMATION (Or please attach a copy of medical insurance card to this form)

Medical Insurance Company: _____________________________________________ Phone:_____________________

Policy Holder’s Name: _______________________________________ Policy/Group ID#: ________________________

ALLERGIC REACTIONS

Please list all allergies (drugs, bites/stings, foods, etc) and indicate if medication (epi-pen or Benadryl) may be administered. Indicate N/A if your child has no known allergies.

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

MEDICATIONS

Please list any medications your child may take during youth ministry trips, retreats, or events

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

ADDITIONAL  INFORMATION

Please provide any additional information about your child that would be important for adult leaders to know

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

CHILD PICK-UP AUTHORIZATION

Parents/Guardians are expected to enter the church to pick up children. Please provide the names of those people who are authorized to pick up your child form church activities.

Name

 

Home Phone

 

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CONSENT: I, the undersigned parent or legal guardian of ____________________________ (Youth’s name) (“Participant”) hereby grant my permission for the Participant to attend and fully participate in future First Presbyterian Church youth ministry activities (e.g. meetings, events, retreats, lock-ins, trips) beginning on the Effective Date of this Permission Form, including trips away from the church premises.

 

LIABILITY RELEASE: In consideration of First Presbyterian Church allowing the Participant to participate in youth ministry activities, I, the undersigned, do hereby release, forever discharge and agree to hold harmless First Church, its pastors, directors, employees, volunteers and teachers (collectively herein the “Church”) from any and all liability, claims or demands for accidental personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the Participant while involved in the youth ministry activities, including without limitation any medical treatments permitted hereunder. Furthermore, I, on behalf of the Participant, hereby assume all risk of accidental personal injury, sickness, death, damage and expense as a result of participation in any recreation or work activities involved therein. The undersigned further hereby agrees to hold harmless and indemnify the Church for any liability sustained by the Church as the result of the negligent, willful or intentional acts of the Participant, including expenses related thereto.

 

MEDICAL TREATMENT PERMISSION: I authorize an adult youth leader to consent to any emergency x-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment and hospital care, to be rendered to the Participant under the general or special supervision and on the advice of any licensed physician or dentist. I give permission for an adult youth leader to give the Participant approved over-the-counter medications (i.e. Tylenol, Advil, antacids, Benadryl) as needed and as directed on the label, to treat non-emergency medical conditions that do not require a doctor or hospital visit such as a minor headache, stomachache, or allergic reaction at a youth ministry activity. The undersigned shall be liable and agrees to pay all costs and expenses incurred in connection with such medical and dental services rendered to the Participant pursuant to this authorization.

 

TRANSPORTATION PERMISSION: The undersigned shall assume all transportation costs and responsibility for transporting the Participant to and from home for the youth ministry activities, including any early return that is necessary for the Participant to return home due to medical reasons, disciplinary action or otherwise. The undersigned hereby gives permission for the Participant to ride in any vehicle driven by an approved and licensed adult leader or volunteer while attending and participating in activities sponsored by the church. The Participant and I understand that SEAT BELTS MUST BE WORN AT ALL TIMES during transportation.

 

__________________________________        x______________________________        ______________

Name of Youth Participant                         Signature of Youth Participant                Date

 

__________________________________        x______________________________          ______________

Name of Parent/Guardian                        Signature of Parent/Guardian                 Date

 

PHOTO RELEASE FOR YOUTH

_____ I grant my permission for First Presbyterian Church use photographs or video taken during church-related activities for use in the church’s publications, website and other materials.

 

_____ I do not grant my permission for First Presbyterian Church use photographs or video taken during church related activities for use in church’s publications, website and other materials


INCIDENT REPORT FORM


A separate form should be completed for each child involved in order to keep the information confidential.        

Nature of Report

Information about Incident and Those Involved

Name of child/youth involved _________________________________________________________________
Address ____________________________________________________        Phone Number _________________
Name of Parent/Guardian ____________________________________________________________________
Address ____________________________________________________        Phone Number ________________
Specific Site of the Incident ____________________________ Date/Time of Incident ____________________
Please describe incident as seen/heard and actions taken
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Any additional relevant information, please document
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Information about Witness(es)
Name ______________________________________________________         Phone Number ________________
Name ______________________________________________________        Phone Number ________________
Name ______________________________________________________        Phone Number ________________


Name and Signature of Person Completing this form ______________________________        Date __________________

*Upon completion of this form, please submit to the Pastor as soon as possible.