Safe Church Application For Staff at Sunnyvale Presbyterian Church

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This information form is being used to help Sunnyvale Presbyterian Church (SVPC) and the Music School provide a safe and secure environment for its children and youth, as well as leaders who participate in its programs and use its facilities. Employees of SVPC and the Music School will complete this form, attend Safe Church training, be fingerprinted and have criminal background and reference checks.

The information obtained from this form is for the use of Sunnyvale Presbyterian Church only.

Note: we suggest you review this form prior to filling it in to ensure you have all relevant information prepared.

BASIC INFORMATION

What is your title at SVPC or the Music School? *

Applicant's Name *

Address *

Cell Phone *

Home Phone

Email *

HISTORY

Describe any health-related training (CPR, first aid, lifeguard, EMT, etc.) you have.

List the name(s) and address(es) of other churches, if any, you have regularly attended during the past five years. *

List any previous or current paid or volunteer work involving children or youth outside of SVPC. (For example, scouting, sports leagues, schools, etc.) Include the organization, city and dates you volunteered. *

PERSONAL REFERENCES

List 4 personal references (only 3 are required for youth and young adults). If possible, try to choose those who have seen you engage with children or youth. Include at least one reference who is not part of the SVPC congregation. Do not include relatives. At least two of these references will be contacted by email, as well as other individuals of our choosing (previous churches, volunteer organizations, others at our church).

Include a current email address for your references. We suggest that you ask your references to add safechurch@sunnyvalepres.com to their list of approved emails.

Reference One Name *

Reference One Email *

Reference Two Name *

Reference Two Email *

Reference Three Name *

Reference Three Email *

Reference Four Name

Reference Four Email

WAIVER AND CONSENT

I affirm that the information I have given in this form is true and correct and that if there are any changes, I will promptly notify Sunnyvale Presbyterian Church (SVPC).

I provide my approval for SVPC to verify the information I have provided on this form by contacting persons or organizations I have named as well as other persons or organizations who may have information concerning me (including law enforcement agencies). I hereby release and agree to hold harmless from liability (a) any person or organization that provides information (including opinions) in connection with this form and (b) Sunnyvale Presbyterian Church and the officers, employees and volunteers, thereof, in connection with the verification of any information provided in this form.

I understand that SVPC may withhold volunteer approval for any reason it deems relevant, and that the exact specifics of this information may not be disclosed to me.

I have read this waiver and the entire application, and am fully aware of its contents. I sign this consent freely and under no duress or coercion.

By typing your name below you effectively provide your signature, indicating that all the information in this form is accurate to the best of your knowledge.

Note: If applicant is under 18, a parent or guardian must also sign this form.

Applicant's Signature *

Date Signed *

YYYY

Date of Birth (if under 18 years old)

YYYY

Parent's Signature (if applicant is under 18 years old)

Date Parent Signed

YYYY

SAFE CHURCH COVENANT STATEMENT

While working as part of a Sunnyvale Presbyterian Church (SVPC) ministry, I agree to provide a safe and supportive environment for all persons who come together in this place. I will do everything within my power to minimize the possibilities of any kind of personal abuse and ensure the safety of those in my care.

Therefore, in all of my church relationships I will seek to:

• Treat all children, youth, and adults with respect and consideration.
• Respect everyone’s rights to decline being touched in ways that make them feel uncomfortable.
• Maintain an attitude of respect, patience, courtesy, appropriate language, and maturity as a positive role model for children and youth.

In situations in which I relate with children and youth, I will seek to:

o Use positive techniques of guidance, such as redirection, positive reinforcement and encouragement rather than competition, comparison, and criticism.

o Have age-appropriate expectations and establish an environment that minimizes the need for discipline.

o Refrain from any behavior that could be considered abusive.

o Be sure the children and youth for whom I am responsible are always well supervised during church activities.

o Not use, possess or be under the influence of alcohol or illegal drugs during the times I am working with children and youth.

o Attend training sessions or forums offered by SVPC dealing with abuse prevention, Safe Church policies and procedures, and appropriate boundaries.

I understand that abiding by these promises and policy guidelines is important and necessary to my participation with children and youth as part of SVPC’s programs. If I fail to abide by them, I realize that I may be reassigned or relieved from my church-related duties at the full discretion of church leadership.

By typing your name below you effectively provide your signature, indicating that all the information in this form is accurate to the best of your knowledge.

Signature *

Date Signed *

YYYY

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