Safe Church Policies and Acknowledgment
Authorized Children and Youth Worker Volunteer Disclosure Form
Email address *
Be Sure to Fill Out This Form in its Entirety and Click SUBMIT at the End.
You will receive an emailed confirmation once the form is submitted.
Last Name: *
Your answer
First Name: *
Your answer
Middle Name:
Your answer
Address: *
Your answer
Daytime Phone:
Your answer
Evening Phone:
Your answer
References
Provide three. One reference should be related to you and the other references should not be related to you.
Name:
Your answer
Address:
Your answer
Telephone:
Your answer
Email:
Your answer
Name:
Your answer
Address:
Your answer
Telephone:
Your answer
Email:
Your answer
Name:
Your answer
Address:
Your answer
Telephone:
Your answer
Email:
Your answer
Attestations
* Please indicate when you began membership or regular attendance.
Your answer
I have never been convicted of, nor pled guilty or no contest to, a crime. (Exclude convictions that have been sealed, expunged or legally eradicated, misdemeanor convictions for which probation was completed and the case was dismissed, or offenses about which inquiry is not permissible in this state) *
Required
If not true, please briefly describe the nature of the crime(s), the date and place of conviction and the legal disposition of the case. The church will not deny a position to any applicant solely because the person has been convicted of a crime. The church, however, may consider the nature, date and circumstances of the offense, as well as whether the offense is relevant to the duties of the position applied for.
Your answer
No civil lawsuit alleging actual or attempted sexual discrimination, harassment, exploitation, or misconduct; physical abuse; child abuse; or financial misconduct has ever resulted in a judgment being entered against me, been settled out of court, or been dismissed because the statute of limitations has expired. *
Required
If not true, give a short explanation of the lawsuit. (Please indicate the date, nature, and place of the incident leading to the lawsuit; where the lawsuit was filed; and the precise disposition of the lawsuit.)
Your answer
I have never terminated my employment, professional credentials, or service in a volunteer position or had my employment, professional credentials, or authorization to hold a volunteer position terminated for reasons relating to allegations of actual or attempted sexual discrimination, harassment, exploitation, or misconduct; physical abuse; child abuse; or financial misconduct. *
Required
If not true, give a short explanation. (Please indicate the date of termination; name, address, and telephone number of employer or volunteer supervisor; and nature of the incident(s) leading to your termination.)
Your answer
Do you have a valid drivers’ license? *
Required
With respect to my driving record, I have not had my license suspended or revoked within the last five years due to reckless driving or driving while intoxicated and/or under the influence of a controlled substance. *
Required
Is there any fact or circumstance involving you or your background that would call into question your being entrusted with the responsibilities of the position for which you are applying? *
Required
If yes, please provide a brief explanation.
Your answer
The covenants between persons seeking authorized volunteer positions in the church require honesty, integrity, and truthfulness for the health of the church. To that end, I attest that the information set forth in this application is true and complete. I understand that any misrepresentation or omission may be grounds for rejection of consideration for, or termination of, the position I am seeking to fill. I acknowledge that it is my duty in a timely fashion to amend the responses and information I have provided if I come to know that the response or information was incorrect when given or, though accurate when given, the response or information is no longer accurate.Beginning such relationships with an open exchange of relevant information builds the foundation for a continuing and healthy covenant between volunteers and the church they seek to serve. To that end, I authorize First Church and/or its agents to make inquiries regarding my character and qualifications, including all statements I have set forth above. I also authorize all entities, persons, former employers, supervisors, courts, law enforcement, and other public agencies to respond to inquiries concerning me, to supply verification of the statements I have made, and to comment on and state opinions regarding my background, character, and qualifications. To encourage such persons and entities to speak openly and responsibly, I hereby release them from all liability arising from their responses, comments, and statements.First Church of Christ’s authorized volunteer and employee recruitment process involves the sharing of information regarding applicants with those persons in a position to recruit, secure, and supervise both the position I am seeking to fill and program I am seeking to participate in. To that end, I authorize First Church and its agents to circulate, distribute, and otherwise share information gathered in connection with this application to such persons for these purposes. I understand that First Church will share with me information it has gathered about me, if I request it to do so. *
Required
Please initial below:
Your answer
Full Name:
Your answer
Today's Date:
MM
/
DD
/
YYYY
Acknowledgement of Guidelines for a Safe Church Environment
First Church of Christ and Ecclesiastical Society of Simsbury, Inc.
Guidelines for a Safe Church Environment
(Revision 7.1 Adopted April 6, 2009)


A. POLICY STATEMENT; DEFINITIONS

ARTICLE I – POLICY STATEMENT

As a Christian faith community, this Church is committed to creating and maintaining programs, activities and an environment in which members of the congregation, minors, staff, volunteers, friends and visitors can worship, work and learn together in an atmosphere that is free from all forms of discrimination, harassment and abuse. That includes a commitment to providing for a safe environment and secure facilities and programs for our congregation and minors, as well as staff, volunteers, friends, and visitors.

The Church is strongly committed to preventing Sexual Harassment and Sexual Abuse, including Sexual Harassment and Sexual Abuse of a Minor. Upon notification, the Church intends to take prompt, appropriate steps to investigate, stop and address any conduct involving a Church member, Employee, Volunteer or visitor that could be construed as Sexual Harassment or Sexual Abuse.

These Guidelines for a Safe Church Environment outline the Church’s policy specifically with respect to Sexual Harassment and Sexual Abuse, including Sexual Harassment and Sexual Abuse of a Minor. They also describe how the Church, acting through its Safe Church Response Team, expects to respond to allegations of Sexual Harassment or Sexual Abuse and, as appropriate, address such conduct and prevent it from recurring.

ARTICLE II – DEFINITIONS

2-a Minor – a person under the age of 18.

2-b Adult – a person age 18 or older.

2-c Church Employee – any paid employee of the Church.

2-d Church Volunteer – any member or friend of the Church who engages in volunteer activity on behalf of the Church.

2-e Church – First Church of Christ and Ecclesiastical Society of Simsbury, Inc., United Church of Christ, located at 689 Hopmeadow Street, Simsbury, Connecticut.

2-f Sexual Harassment and/or Sexual Abuse of a Minor – behavior that includes Sexual Harassment (as defined in 2-g), molestation or sexual exploitation of a Minor and/or other behavior by which an Adult uses a Minor as an object of sexual gratification and/or creates an environment of Sexual Harassment as defined in 2-g.

2-g Sexual Harassment – repeated or coercive conduct of a sexual nature or sexual advances toward another person contrary to his or her wishes. Sexual Harassment includes, but is not limited to, behavior directed at another person with the intent of intimidating, humiliating, or embarrassing the other person, or subjecting the person to public discrimination. Unwelcome sexual advances, requests for sexual favors, and other verbal or physical conduct of a sexual nature constitute Sexual Harassment when:

1. Submission to such conduct is made either explicitly or implicitly a term or condition or circumstance of an individual’s employment;

2. Submission to, or rejection of, such conduct by an individual is used as a basis for evaluation in making employment decisions affecting an individual; or

3. Such conduct has the purpose or effect of unreasonably interfering with an individual’s performance or participation in Church activities or creating an intimidating, hostile, or offensive work environment.

Sexual harassment includes continuing to directly or indirectly express sexual interest after being informed directly that the interest is unwelcome and using sexual behavior to control, influence, or affect the career, salary, benefits, work, learning, or worship environment of another. It also includes suggesting, threatening, or implying that failure to accept a request for a date or sexual intimacy will affect a person's job prospects, church leadership, or comfortable participation in the life of the church.

2-h Safe Church Response Team – the Safe Church Response Team consists of the Senior Minister, Associate Minister of Youth and Young Adults, Church School Director, President of the Congregation, and Chair of the Personnel Committee. If an allegation of Sexual Harassment or Sexual Abuse is made against any member of the Safe Church Response Team, the Chair of the Board of Elders will replace that person on the Team. The Safe Church Response Team will meet at least once a year.

B. SEXUAL HARASSMENT OR SEXUAL ABUSE OF A MINOR

ARTICLE I – REPORTING OF AND RESPONSE TO ALLEGATIONS OF SEXUAL HARASSMENT OR SEXUAL ABUSE OF A MINOR

1-a Any person who reasonably believes that an incident of Sexual Harassment or Sexual Abuse of a Minor has occurred within the Church community is encouraged to report the matter to either a member of the Safe Church Response Team and/or the Connecticut Conference of the United Church of Christ (UCC).

1-b A Church Employee or Church Volunteer who reasonably believes or has direct knowledge of any behavior or incident that could be construed as Sexual Harassment or Sexual Abuse of a Minor must report that information immediately to a member of the Safe Church Response Team.

1-c Upon receipt of an allegation of Sexual Harassment or Sexual Abuse of a Minor, the Safe Church Response Team shall:

1. When appropriate for guidance, promptly contact any attorney who may be retained by the Church in connection with this matter;

2. When appropriate, notify the insurance carrier for the Church and advise the Connecticut Conference of the UCC;

3. Inform the individual alleged to have been involved in Sexual Harassment or Sexual Abuse of a Minor that he/she may not minister to any Minor until an investigation of the matter by the Safe Church Response Team is complete and the allegations are considered resolved and addressed by the Safe Church Response Team;

4. Keep all aspects of the handling of the allegations documented and, to the extent permissible by law, maintain the confidentiality of the investigation;

5. If needed, designate one member of the Safe Church Response Team as the spokesperson for the Church to communicate to the congregation, the media and others, as appropriate;

6. Upon reasonable cause to believe that the allegations of Sexual Harassment or Sexual Abuse of a Minor have been substantiated, the Safe Church Response Team shall take whatever immediate, effective and appropriate remedial action is warranted under the circumstances, including such reporting as may be required to governmental and police authorities.

7. Offer both parties pastoral care as appropriate.

C. SEXUAL HARASSMENT OR SEXUAL ABUSE OF AN ADULT WITHIN THE CHURCH WORKPLACE OR COMMUNITY

ARTICLE I – REPORTING OF AND RESPONDING TO ALLEGATIONS OF SEXUAL HARASSMENT OR SEXUAL ABUSE OF AN ADULT

1-a Any person who reasonably believes that an incident of Sexual Harassment or Sexual Abuse of an Adult has occurred within the Church workplace or community or who claims to be a victim of Sexual Harassment or Sexual Abuse is encouraged to report the matter to either a member of the Safe Church Response Team and/or the Connecticut Conference of the UCC.

1-b A Church Employee or Church Volunteer who reasonably believes or has direct knowledge of any behavior or incident that could be construed as Sexual Harassment or Sexual Abuse must report that information immediately to a member of the Safe Church Response Team.

1-c The procedures to be followed by the Safe Church Response Team upon receipt of an allegation of Sexual Harassment or Sexual Abuse of an Adult are described in Section B, Article I-c, above.

D. PREVENTIVE MEASURES

ARTICLE I – BACKGROUND/REFERENCE CHECKS AND VOLUNTEER PLACEMENT REVIEWS; RECORDKEEPING

1-a All Church Employees will undergo an appropriate background/reference check prior to the start of their employment, and any offer of employment at the Church will be subject to the candidate’s successful completion of the background/reference checking process.

1-b All Church Volunteers will undergo an appropriate placement review process conducted by the Safe Church Response Team or its designee. As part of this process, every Church Volunteer will be required to fill out an application approved by the Safe Church Response Team.

1-c Background investigation and reference checking documents related to Church Employees will be retained in separate files maintained at the Church office by the
Church Administrator; placement review documents related to Church Volunteers will be retained in separate files maintained at the Church office by a designee of the Safe Church Response Team. Such documents will be considered confidential and will be available only to the Church Administrator (in the case of Church Employee documents), Safe Church Response Team, counsel to the Church, insurance representatives, authorized representatives of the Connecticut Conference, and others with a legitimate need to know or as required by law or judicial process.

ARTICLE II – TRAINING

The Safe Church Response Team may require periodic training (e.g., seminars) for all Church Employees, Church Volunteers, and other persons who are covered under these Guidelines. The need for such training will be determined by a majority vote of the Safe Church Response Team.

ARTICLE III – APPROPRIATE SUPERVISION AND IMPLEMENTATION

All programs, events, and ministries shall take place in appropriate settings and with appropriate supervision as the case may be.

The Church and appropriate committees and boards will implement suitable and prudent operational procedures in all programs and events.

Please initial below:
Your answer
Full Name:
Your answer
Today's Date:
MM
/
DD
/
YYYY
SAFE CHURCH GUIDELINES for YOUTH MINISTRY
SAFE CHURCH GUIDELINES for YOUTH MINISTRY

OVERVIEW
First Church of Christ, Simsbury, CT, is committed to creating a safe and healthy environment in which young people can learn about and experience God’s love. Therefore we will provide supervision for all ministries and activities involving youth and employ practices that provide for the safety of all youth participants as well as teachers, leaders or helpers who serve in these ministries.

YOUTH MINISTRY DEFINITIONS
Junior Fellowship (JF): Youth group for 7th and 8th graders.
Confirmation: Preparation for affirming one’s baptism and joining First Church, Simsbury, for 8th graders and high school students.
Pilgrim Fellowship (PF): Youth group for high school students.
Junior Advisor: A person 18-22 years of age.
Adult Advisor: A person 23 years of age and older. Adult Advisors can transport students.
Youth: A person in grades 7 through 12

POLICIES and PROCEDURES
Two Adult Advisor Policy and Procedures:

The Two Adult Advisor Policy is intended to protect youth and prevent adults from encountering a situation where they could be wrongfully accused. Therefore, no adult should be alone in the church, or be at a church-approved activity, with a youth that is not related to him or her. It is recommended that there be a ratio of one adult for every seven youths at all youth programs or activities. If these ratios are unable to be met, the youth activity may be canceled at the discretion of the minister or lay leader.

At least two Adult Advisors should wait with youth being picked up after an offsite event. In the event that an adult is alone with a youth waiting to be picked up, they should wait in a public space.

It is permissible to have one Adult Advisor per car carrying youth to an off-site event, but at no time should an adult be alone with a child other than his/her own. Two children and one adult in a vehicle is appropriate.

Five Year Older Policy:

It is recommended that all Adult Advisors for youth activities or off site events be at least five years older than the oldest participant in the class, group or activity.

Permission, Medical, and Covenant Forms:

All Youth participating in youth programs must have a First Church of Christ, Simsbury, CT, Youth Information Form on file. These forms will be kept on file for the year with the church. Completed forms will be brought on all off site events by the adult leader.

All Adult Advisors must have a First Church of Christ, Simsbury, CT, Adult Information Form on file. These forms will be kept on file for the year with the church. Completed forms will be brought on all off site events by the adult leader.

All Youth and Adults participating in programs will sign a covenant and submit it along with their Youth or Adult Information Form.

Off-Site Event Guidelines:

Parents or guardians and participating youth shall be given information ahead of time about programs, activities, leaders, chaperones, dates, times, cost, method of transportation, purpose of the scheduled trip or activity and other details whenever possible.

All occupants of a vehicle must use an individual seat belt (no multiple belting) at all times during the operation of the vehicle.

No cell phone use while driving except for a true emergency, and then the driver is encouraged to pull off the roadway to a safe spot.

Appropriate supervision: The two Adult Advisor policy and procedures applies for all church events including those held off-site. On an overnight trip there will be at least one male and one female chaperone.

Health and Safety:

A first aid kit is available in the Youth Room. Fire safety information, emergency evacuation routes and meeting place is posted in the Youth Room as well. If there is a medical emergency, the parents and the minister should be contacted and 911 called as warranted. The importance of hand washing before handling food and after any clean up is emphasized.

Concern for a Youth’s Safety Outside of Church:

If in the context of a class or other event, a youth discloses information that raises concern about his or her safety, the incident should be discussed promptly with the Associate Minister for Youth and Young Adults to clarify and determine an appropriate level of response.

INTERNET SAFETY
The internet and social media are evolving tools which offer great promise for developing and deepening ministries but also pose significant safety challenges.

Definitions:

Church Sponsored Sites — any group, page or list-serve that is created by a designated member of First Church, Simsbury, for the purpose of establishing, maintaining or growing ministries to and with youth and/or adults.

Inappropriate Content — refers both to content that is improper or offensive, but also content that might be suited to the medium but not to the relationship.

Minor to Adult Relationships:

Adults should not submit “friend” requests to minors or youth. Youth may request friendships with adults, and adults should discern the level of contact they want to maintain with youth prior to responding to these requests.

When and where available, adults may choose to create separate private and professional profiles on networking sites to create a line of privacy.

If an adult chooses to accept friend requests from minors or youth that are associated with JF or PF, it is recommended that other adults have full access to the correspondent’s profile and correspondence. The Safe Church Response Team is permitted to request correspondence between a Youth and Adult at any time.

Adults who choose to accept friend requests from youth should use all privacy settings applicable to shield youth from any inappropriate content that may exist within the adult’s profile.

All youth and adults should be informed that any communication that is sent via digital means (email, social networking site notes or posts, texts, etc.) is not confidential and may be reported or shared with others.

Adults should archive or save all email correspondence with youth.

“Closed” but not “hidden” groups should be used for JF and PF. These groups should have both youth and adult administrators.

Clergy who work directly with youth are encouraged to use church sponsored digital communications groups to maintain contact with youth members.

*
Required
Please initial below:
Your answer
Full Name:
Your answer
Today's Date:
MM
/
DD
/
YYYY
A copy of your responses will be emailed to the address you provided.
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This form was created inside of First Church of Christ, Simsbury, CT. Report Abuse - Terms of Service - Additional Terms