ABCDEFGHIJKLMNOPQRSTUVWXYZ
1
Statement of Compliance
2
3
This form should be completed and submitted one week prior to arriving at camp.
4
5
6
7
The volunteering Adult Chaperones/Leaders named below are known to the staff or recognized leadership of the participating church and the church knows of no reason why any should not serve as a sponsor for children and youth under the age of eighteen (18). The church confirms that it has taken reasonable steps to confirm that the individuals are not registered sex offenders by making inquiries to law enforcement officials or by checking www.nsopr.gov (the National Sex Offender Public Website). In addition, participating church warrants that it has used __________________________________________ company to perform nationwide criminal background checks on all Adult Chaperones/Leaders. Participating church warrants it has brought no Adult Chaperone/Leader not listed on this form.
8
9
10
11
12
13
While we acknowledge that there are many diffferent reputable companies to assist you with the criminal background check process, Protect My Ministry and Lifeway already provides this type of service to many of our participating churches. You can go to protectmyministry.com or lifeway.com to find out more about the services they offer.
14
15
16
17
By signing this form you are stating that you have checked all adult sponsors with the national sex offender public website and ran a background check on each adult.
18
19
20
21
Names of all Adult Chaperones/Leaders:
22
23
1.14.
24
2.15.
25
3.16.
26
4.17.
27
5.18.
28
6.19
29
7.20.
30
8.21.
31
9.22.
32
10.23.
33
11.24.
34
12.25.
35
13.26.
36
37
Church Name:
38
Address:
39
City:ST:Zip:
40
Phone Number:Email Address:
41
42
43
44
DateAuthorized Representative SignatureName Printed
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100