Volunteer Release Form

Second Presbyterian Church

  Child Protection Policy - Screening Form for Volunteers

 This screening form is required of all volunteers involved in the supervision or custody of children and youth at Second Presbyterian Church.  It will be used to help the church provide a safe environment for all children and youth who participate in its programs.

Please complete all questions.  The information provided will be held in strict confidence.

 

Name__________________________________________________            Date___________________

 

Address_____________________________________________________________________________

 

Are you now a resident of the Commonwealth of Virginia? ______    If so, how long have you resided continuously in Virginia? _____________________

 

Home Phone_________________    Work Phone _________________  e-mail ____________________

 

Drivers license number_____________________    State_____________________________________

 

Date of birth______-______-______                             

 

Occupation______________________________      Employer_________________________________

 

Are you a member of Second Presbyterian Church? _______    If so, year joined__________________

If not, or if you have been a member for less than six months, please list previous church membership:

 

Church name__________________________________________ City ______________ State _______

 

How long were you a member there? _______________________

 

Yes         No

___       ___           Have you ever been convicted of a criminal offense involving the possession, use, manufacture or sale of drugs, or involving a sexually related crime?

 

___       ___           Have you ever been arrested for, or convicted of any criminal offense, excluding minor traffic violations?

 

___       ___           Has any administrative or civil claim or suit ever been filed against you alleging sexual harassment, sexual assault, sexual abuse, assault or battery?

 

___       ___           Have you ever been hospitalized or treated for alcohol or substance abuse?

 

___         ___         Have you ever been denied an opportunity to supervise youth activities for any reason?

 

 

Please fully explain any “yes” answers above, including the outcome of any arrest, conviction, treatment, proceeding or denial you have disclosed.  Continue on back if necessary.

 

 

Disclosure

 

In compliance with the Child Protection Policy at Second Presbyterian Church, all paid staff and all scheduled volunteers will be screened before working with children or youth.  This may include a background check to rule out any record of prior child abuse.

 

 

Authorization

 

I acknowledge that I have read, understand and agree to abide by the Second Presbyterian Church Child Protection Policy and have received a copy for my personal use.

 

I acknowledge that I have read and understand this disclosure and authorization form, and understand that it is legally binding.

 

I authorize a background check to be conducted on me to rule out any record of prior child abuse, and I understand that a record of information obtained will be kept in a confidential file by the church.

 

I authorize any person, firm, institution or agency contacted to furnish the above mentioned information and I release all parties involved from any liability and responsibility for doing so.  I sign this release as my own free act in exchange for the opportunity to serve as a Second Presbyterian Church volunteer.  This authorization shall be valid in original, faxed, electronic, or copied form.

 

I agree to follow the Child Protection Policy and to refrain from inappropriate conduct in the performance of my service on behalf of Second Presbyterian Church.  I understand that any violation of this Child Protection Policy or misrepresentation of information that I have provided may result in termination of volunteer opportunities with children or youth.

 

Signature                                                                                            Date

 

                                                Printed Name

 

 

Your social security number, required to obtain a background check, will not be kept on file.  It will be shredded as soon as the background check is secured.  You may inspect your file upon request.

…………………………………………………………………………………………………………………………………………………………………

 

   Social Security Number ________________________Name _________________________________