CENTRAL PRESBYTERIAN CHURCH

IV. Screening and Evaluation of Staff, Compensated Childcare Providers, and Volunteers

A. Staff, Compensated Childcare Providers, Volunteers, Persons in Leadership Positions

Appendix 6 Blanket Parent/Guardian Permission Slip for Local Off-Site Activities

“Whoever welcomes one such child in my name welcomes me, and whoever welcomes me welcomes not me but the one who sent me.” Mark 9:39

The Safe Child Policy Program Manual was developed to establish a proactive policy to help keep children and adults safe at Central Presbyterian Church activities. This was fueled by national awareness of numerous incidents of child sexual abuse and accusations of child sexual abuse in the church setting. Whether substantiated or not, these have had a profoundly devastating effect on the individuals and churches involved. The church, as a trusting, loving, and open place, is particularly vulnerable to the problem. The result of many hours of study and prayer, this manual establishes a policy intended to minimize the possibilities for abuse and the opportunities for false accusations. These guidelines are intended to provide a safe, secure environment for the nurture of all children of God.

God embraces children and youth with love, placing their nurture and care in our hands. We want them to know that at Central Presbyterian Church they will find loving and caring Christians who provide a safe environment for them.

It is our mission to establish policies and procedures which promote the physical and emotional safety of the children and youth who participate in the programs of Central Presbyterian Church, while reducing the legal vulnerability of our church, the congregation, and the staff.

To further these goals, we will adhere to and continue to develop strategies that support the following key policies:

1. Educate staff, unpaid servant workers, and parents to aid in the prevention of physical and emotional abuse of children and youth.

2. Establish policies that create barriers for physical or emotional abuse of children and youth within Central Presbyterian Church programs.

3. Encourage leaders, unpaid servants, and participants to report improper behavior.

4. Establish a protocol for immediate and thorough response to reports of improper behavior.

The implementation of these policies should go far towards assuring the physical and emotional safety of all the children and youth participating in Central Presbyterian Church’s programs.

“Child” or “Children” shall mean persons from birth through fifth grade of grammar school.

“Church Premises” shall mean the property, buildings, and improvements located at 31 N 7th Street

“Compensated Childcare Providers” shall mean persons employed by the Church to provide childcare services in exchange for monetary compensation; provided, however, that this term shall not include any person who is a member of the staff.

“Pastor” shall hereinafter collectively refer to the Pastor/Head of Staff and the Associate Pastor(s).

“Policy” shall mean this Safe Child Policy Program Manual and all subsequent amendments, revisions, and supplements thereto.

“Staff” – shall include all persons who are employees of the Church including, but in no way limited to, Senior Pastors and Associate Pastors; provided, however, that this term shall not include persons who are employed as Compensated Childcare Providers as that term is defined above.

“Volunteers” shall mean any persons who, for no compensation, provide educational and/or childcare services for or in connection with Church programs, activities, or events and have regular contact with Children or Youth.

“Youth” shall mean persons from sixth grade through and including age seventeen.

The Safe Child Oversight Team shall consist of at least two (2) members, and shall have no more than eight (8) members. Members of the Safe Child Oversight Team should include at least one (1) member of Session, the Pastor/Head of Staff or an Associate Pastor, and one (1) Staff member responsible for Child and Youth programming. The Safe Child Oversight Team shall be responsible for many of the routine functions related to this Policy including reporting Church Premises safety concerns to the Trustees and following up to insure that corrective measures are taken to address the concerns; reviewing incident reports, fielding questions and concerns about this Policy, modifying, amending, revising, or supplementing this Policy when necessary, and reporting to Session. The Safe Child Oversight Team shall also be responsible for conducting an annual walk through inspection of the Church Premises for the purpose of assessing potential safety concerns for Children or Youth.

The Safe Child Response Team shall be appointed by Session and shall consist of two (2) appointed members from Session and the Pastor/Head of Staff or an Associate Pastor. The Safe Child Response Team shall be responsible for responding to any reports or accusations of questionable or inappropriate behavior towards Children or Youth that occur on the Church Premises or at any Church programs or activities.

Parents and guardians are encouraged to notify the Staff if their Child or Youth has any special needs that would require adaptations to this Policy. The Staff will work with the family, leaders, and/or special consultants to provide reasonable and appropriate adaptations that will allow for a positive experience for all involved.

IV. SCREENING AND EVALUATION OF STAFF, COMPENSATED CHILDCARE PROVIDERS, AND VOLUNTEERS

This section sets forth the screening and evaluation procedures that shall be used in examining and hiring Staff, Compensated Childcare Providers, and Volunteers who routinely have contact with Children or Youth.

Any potential Staff member or Compensated Childcare Provider shall complete an application in substantially the form set forth in Appendix 1 hereto. All records relating to the applicant shall be kept confidential and will be seen only by the Pastors and the office manager.

A Pastor and/or his/her designee shall contact the references listed in the application by telephone and record information given by the reference. The written record of the telephone conversation shall be kept with the application. Appropriate references include adult persons who are unrelated to the applicant and fall within any of the following categories:

i. board members or other leaders in congregations in which the applicant has served;

Either Pastor or their designees shall annually review all Compensated Childcare Providers. The

evaluation procedure will include input from the supervisor, parents, and others as deemed appropriate.

i. a first-time Volunteer shall complete an application in substantially the form set forth in Appendix 2 hereto. All records relating to a Volunteer’s application shall be kept confidential and will be seen only by the Pastor and/or office manager;

ii. the Pastor/Head of Staff, Associate Pastor, or person(s) in charge of Child or Youth programming shall meet with a first-time Volunteer to assess the person’s fitness for the volunteer position sought;

iii. Volunteers who are husband and wife may team-teach, supervise, or chaperone a Child or Youth activity or program without the presence of an unrelated adult so long as the activity, program, or class is, at all times, visibly open. In all other cases, a non- related adult must be present.

All Staff and Compensated Childcare Providers shall be subject to criminal background checks. The Pastors will be the only persons permitted to review the criminal reports. Reports will be kept in a locked file cabinet in the office manager’s office. A negative criminal background report shall result in a denial of the application. The results of criminal background reports will not be shared with members of the congregation.

Each year, Staff members, Compensated Childcare Providers, and Volunteers shall be required to confirm in writing their familiarity with the Policy by filing the form attached hereto as Appendix 3.

A. Staff, Compensated Childcare Providers, Volunteers, Persons in Leadership Positions

All Staff members and Compensated Childcare Providers must be provided with initial training relating to this Policy within thirty (30) days after their first day of compensated service to the Church. All Volunteers and persons in leadership positions (Deacons, Trustees, Session) must attend an annual training session relating to this Policy. The purpose of the training is to familiarize persons with this Policy and any amendments hereto, and any other childcare or safety policies adopted or approved by the Church.

Any adult participating in Vacation Bible School must complete the acknowledgment form attached as Appendix 4.

During new member orientation classes, prospective and new members will be informed about this Policy by the person(s) leading the classes and/or his/her/their designee. Prospective and new members shall be advised as to where they can receive a copy of this Policy and shall receive an overview of the Policy and the purposes therefore.

An informational article, prepared by at least one (1) member of the Safe Child Oversight Team, will appear in the Church newsletter once a year. The article shall specifically emphasize:

i. the names of the members of the Safe Child Oversight Team and the Safe Child Response Team;

ii. an explanation of the open door policy and any other provision of this Policy that the author deems pertinent; and

PARENTS OF CHILDREN AND YOUTH IN THE CHURCH ARE AND WILL BE ENCOURAGED TO INSTRUCT THEIR OWN CHILDREN IN SAFE CHILD ISSUES.

Signs and/or notices shall be posted in classrooms stating that the Church has a Safe Child Policy and that copies of this Policy are available upon request.

All Children and Youth of member parents or guardians must be registered annually with the Church to attend Church sponsored programs and activities. The registration form is attached as Appendix 5. At the beginning of the school year, a permission slip in the form attached as Appendix 6 shall be completed and returned to the director of Child and Youth programming for all Children and Youth of member parents or guardians. The Children and Youth of non-member parents or guardians must be registered annually with the Church after attending three (3) Church programs or activities in the applicable year. Attendance shall be taken at each activity or program for Children and/or Youth.

All Children kindergarten age and above, must wear a nametag during Church-sponsored activities and programs. It is requested that all Youth wear a nametag during Church-sponsored activities and programs. It is further requested that all Staff, Compensated Childcare Providers, and Volunteers working with Children or Youth in Church-sponsored programs or activities wear a nametag.

A roster of all teachers, assistants, substitutes, Compensated Childcare Providers, and Volunteers will be maintained and updated quarterly and kept on file with the Associate Pastor.

Unless otherwise specified herein, all rooms are to be staffed with at least two (2) unrelated adult leaders at all times. If this is not possible to meet this requirement, an appropriate Staff person (i.e., Pastor or designee) will monitor the room on a regular basis.

Additionally, the following ratios will be observed in classrooms of children from birth through age six (6):

Any preschool which is housed at the Church will observe the National Association for Education of Young Children’s guidelines, which mandates one (1) adult per ten (10) children.

The Parents of Children and Youth participating in Church-sponsored programs and activities, Pastors, and Staff, shall have the right to visit and observe the programs/activities at any time, unannounced. For the protection of all persons involved, at no time shall any adult working with Children or Youth have a one-on-one meeting with a Child or Youth behind closed doors. At the very least, an adult engaged in a one-on-one meeting with a Child or Youth shall keep the door to the meeting room partially open for the duration of the meeting.

No Child or Youth should be left unsupervised in the Church buildings or on Church grounds. Supervision for Sunday Church School and other programs or activities for Children and/or Youth will begin at least five (5) minutes before the stated starting time for the class, program, or activity and continue up to five (5) minutes following the scheduled ending time for the class, program, or activity. Any exceptions to this rule must be cleared directly with the teacher/leader or the specific class, program, or activity. Parents or guardians shall be responsible for the supervision of their Child(ren) and/or Youth at all other times. Release authorization may be given for Children or Youth whose parents desire that they be released independently or to another family member (forms for this purpose are located in the childcare rooms).

For non-Sunday school programs, events, and activities, parents of Children and Youth shall arrange in advance for their Child or Youth to be transported to and from Church-sponsored programs and activities. If the Child or Youth is not picked up within ten (10) minutes of the scheduled conclusion of the program, event, or activity, the program leader or responsible adult shall contact the Child or Youth’s parent(s) or legal guardian(s) so that the parent(s) or legal guardian(s) can make immediate arrangements to have the Child or Youth picked up.

When a preschool Child or a Child who needs assistance uses the bathroom, an adult may assist but must observe the following guidelines:

a. no one under the age of thirteen (13) may help a Child in the bathrooms unless accompanied by an adult; and

An adult should escort a group of Children of any age to the bathroom. It should be the aim to always go as a group. Adults should try to avoid taking a Child to the bathroom alone. If it is necessary for an unrelated adult to take a Child to the bathroom alone, the adult shall observe the open door policy. If a Child must be sent to the bathroom alone, the adult who sent the Child to the bathroom should establish a short time frame for the Child’s return to the classroom, program, or activity.

There is no established bathroom procedure for Youth. Youth shall be permitted to use the bathroom without adult assistance or oversight; provided, however, that Youth shall notify the program or activity leader, or the responsible adult before leaving the classroom, or program or activity to use the bathroom.

Both men and women may change diapers. Youth servants assisting in the nursery must be at least thirteen (13) years of age to change diapers. Anyone changing diapers in the Church buildings or premises shall comply with the following procedure:

6. wipe the Child from front to back, changing the wipe before wiping the front again;

7. when cleaning uncircumcised males, gently retract the foreskin (never force), wipe area, and then return foreskin back out;

11. discard diaper, gloves, and wipes into designated container (using new gloves if desired);

13. disinfect area with bleach water (using gloves if desired), and return bleach water to out-of-reach storage space; and

When transporting Children or Youth to an activity, all drivers must be over the age of twenty-five (25) and have a copy of a valid operator’s license and current automobile insurance on file with the office manager. The license plate number of the vehicle and the cellular telephone numbers of the driver and all other adults in the vehicle shall be left with the Pastor before departing.

The number of persons per car should not exceed the ratios set forth in Section VI(C) above, where applicable, or the number of seat belts in the vehicle. All occupants must use seat belts at all times.

Church-authorized transportation shall be used for Children and/or Youth participating in Church-sponsored activities away from the Church premises.

It is the responsibility of the parents/guardians to provide/approve transportation to and from the origination point for off-site Church programs and activities.

Overnight and/or off-site activities for the Youth must be pre-approved by a Pastor. Some off-site Youth activities may be spontaneous in nature. At the beginning of each school year, the Pastors, in conjunction with the person in charge of youth programming, will determine what types of off-site Youth activities are approved. When possible, parents of the prospective Youth participants will be notified of the activity at least two (2) weeks prior thereto. A proposed itinerary in the form attached hereto as Appendix 7 must be submitted to a Pastor prior to the overnight and/or off-site activity. When possible, the proposed itinerary shall be submitted to a Pastor at least three (3) weeks prior to the activity.

A Youth will not be permitted to attend any overnight or off-site activity outside of Tippecanoe County unless his/her parent(s) or legal guardian(s) sign and return a permission slip in the form attached hereto as Appendix 8, and a medical release in the form acceptable to the Pastor(s).

There must be at least two (2) unrelated adult leaders present for any off-site Youth activity. At least one (1) of the adult leaders shall carry with him/her the following: (i) a copy of the Church’s insurance coverage; and (ii) duplicate copies of the permission slips and medical releases for each Youth attending the activity.

For overnight activities, a list of the adult leaders and/or chaperones shall be submitted to a Pastor for review and approval. Approval and/or disapproval of an adult leader or chaperone shall be at the Pastor’s sole discretion. There shall be no overnight activities for Children younger than third grade unless it is a specific parent/child activity.

All overnight activities must have at least two (2) unrelated adult leaders supervising the activities. If the group is coeducational, there must be at least two (2) unrelated adult males and two (2) unrelated adult females to accompany and supervise the group. Where applicable, the adult/child ratios set forth in Section VI(C) shall be followed. Separate sleeping areas for male and female participants must be provided. At least one (1) of the adult leaders shall carry with him/her the following: (i) a copy of the Church’s insurance coverage; and (ii) duplicate copies of the permission slips and medical releases for each Youth attending the activity.

Touch is an essential responsibility in nurturing lives. Physical contact with Children and Youth should be developmentally appropriate. Be aware of and sensitive to differences in sexual development, cultural differences, family backgrounds, individual personalities, and special needs. The following guidelines are to be promoted for pure, genuine, and positive displays of God’s love.

i. Hugs - Avoid initiating full contact, body-to-body hugs/kisses with a Child or Youth;

ii. Lap Sitting – Children five (5) years or younger may sit on an adult’s lap. Discourage lap sitting with school age Children; rather, encourage them to sit beside you. Youth should not be permitted to sit on an adult’s lap.

iii. Casual touch - Gentle contact during activities may occur in the form of pats on Child or Youth’s head, shoulders, arms, or hands.

At no time shall any adult working with Children or Youth pursue a dating, sexual, or romantic relationship with a Child or Youth. No adult working with Children or Youth shall communicate with a non-relative Child or Youth via text messaging, telephone, internet, or online social network sites for the purpose of developing, proposing, suggesting, initiating, or otherwise pursuing a dating, sexual, romantic, or otherwise inappropriate relationship with a Child or Youth. Where possible, copies of any written or electronic communications between an adult working with Children or Youth and a Child or Youth shall be sent to the parent(s) or guardian(s) of the Child or Youth. This provision shall not prohibit communications between Staff or Volunteers to a Youth elected to a board, ministry team, or Pastor or Church officer nominating committee relating to events, meetings, agenda, and activities of said board, ministry team, or committee.

All adults working with Children or Youth in a Church-sponsored activity, program, or event shall refrain from consuming alcohol, illegal drugs, or tobacco during the entire course of the Church-sponsored activity, program, or event.

Staff, Volunteers, Compensated Childcare Providers, teachers, and adult leaders shall not give gifts to individual Children or Youth without the prior knowledge of the parent(s) and/or supervisor or responsible Pastor. Gift giving should be done on a group basis for special occasions only. Gifts should not be elaborate and should be appropriate to the occasion.

Any interaction regarding discipline needs to carefully consider a Child or Youth’s dignity and well-being. Gentleness, respect, and understanding must guide all actions and words. Discipline will be carried out through instruction, training corrections, and positive reinforcement. Reinforce good and appropriate behavior with praise and thanks. Should a disciplinary problem arise, keep the following in mind:

4. the Child or Youth should know the consequences of his/her behavior ahead of time, if possible; and

5. time-out is an acceptable method of redirecting a Child having difficulty. A good rule of thumb is one (1) minute of time-out per year of the Child’s age (i.e., a 5 year old Child could sit out for 5 minutes). If time-out is used, the Child is removed from the group, but is not left unsupervised. A chair in the corner of the classroom is acceptable.

The following guidelines have been developed to encourage Staff, Compensated Childcare Providers, and Volunteers to react consistently when inappropriate behavior occurs. For the purpose of these guidelines, inappropriate behavior is defined as any action that can cause harm or show disrespect to self, others, or the content of the room. The following steps should be followed upon observing inappropriate behavior:

3. remind the Child or Youth that if the action continues a consequence will ensue;

6. after taking action, remind the Child or Youth of an alternative behavior; and

7. for third offenses, the Child or Youth should be removed from the activity and the parents of the Child or Youth shall be contacted.

In extreme cases where the Child or Youth becomes a threat to him/herself or others, remove the Child or Youth from the room. Do not leave the Child or Youth unattended.

The Pastors or their designees shall be contacted for any situation that cannot be handled in accordance with the above guidelines.

An Accident / Incident Report (Appendix 9) must be completed by the activity leader/person observing any accidents, injuries, or substantial disciplinary problems/incidents involving any Child or Youth, immediately following the accident, injury, or incident. The report should be given to a Pastor who will notify the parent(s) of the Child or Youth. The Pastor(s) shall keep the original of the Accident / Incident Report and provide a copy thereof to the parent(s).

It is considered appropriate for photographs of Children and Youth to be posted within the Church buildings. If any photograph is to be published publicly, including on the Church website, prior written approval shall be required.

The parent(s) or guardian(s) of Youth involved with boards, ministry teams, Pastor or Church officer nominating committees, shall arrange for their Youth’s transportation to and from meetings and events.

Any questionable or inappropriate behavior towards Children or Youth, which occurs on the Church premises or at any Church activity or event, must be reported to a Pastor. Questionable or inappropriate behavior toward a Child or Youth shall include, but is in no way limited to, any behavior that gives the observer reason to believe a child is the victim of abuse, bullying, rape, neglect, incest, or molestation (hereinafter “Crime Against a Minor”). For purposes of this Policy, the term “reason to believe” shall mean evidence which, if presented to individuals of similar background and training, would cause those individuals to believe that a Child or Youth was a victim of a Crime Against a Minor.

Any person who suspects that a Child or Youth is a victim of a Crime Against a Minor should report these suspected violations to a Pastor.

Any suspected Crime Against a Minor should be reported to a Pastor. All Pastors shall be informed of the report. If the Pastors comprise fewer than three (3) people, or if one (1) or more of the Pastors is the accused person, then the Clerk of Session shall also be informed of the report. Within two (2) days of the initial report of a suspected Crime Against a Minor, the initial reporter or the Pastors, or the Clerk of Session in consultation with the initial reporter, must make a written incident report. This report is to be kept by the office manager.

If a Crime Against a Minor is suspected, the Pastors and/or the Clerk of Session shall promptly call for a meeting of the Safe Child Response Team. The Safe Child Response Team shall make an external report to the Child Protective Service (or consult with the Service, if necessary, to discuss the need for a report).

Upon receipt of an allegation of a Crime Against a Minor, the Safe Child Response Team should follow the following Action Plan:

b. determine appropriate follow-up actions, among them making immediate decisions about removal of the accused from direct contact with Children and Youth;

c. appoint a contact person from the Safe Child Response Team to communicate with the parents of the victim as soon as possible, and to maintain communication with them as appropriate throughout the response process;

f. contact the General Presbytery and Stated Clerk of Presbytery of Wabash Valley;

h. ask Session to appoint a specific spokesperson for communication with congregation and media, as needed;

j. document all actions and abuse incident reports in writing and store within a locked file with the office manager, maintaining confidentiality of all involved. This locked file will be maintained by the office manager and may be accessed by the Pastors and the Clerk of Session, unless otherwise directed by Session.

If one of the members of the Safe Child Response Team is the accused person, the remaining team members, who are not related to the accused person and do not have a business relationship with the accused person, shall establish a replacement from the membership of the Church.

This Policy and the forms appended hereto are subject to amendment and revision upon majority vote of the Session.

APPENDIX 1

Applicant Name (first, middle, last): _______________________________________________

Phone (h):____________ Phone (w):____________ Fax:___________________ E-Mail:___________

d/o/b: ____________ Social Security No.: _____________ Drivers License No.: _____________

Position for which Applicant is Applying: _________________________________________________

References: Please the requested information for at least three (3) unrelated persons who are (1) board members or other leaders in congregations in which you have served or worked, (2) members in other organizations in which you have served or worked, and/or (3) past employers.

________________________________________________________________________________

For Office Use Only:

SCOT Recipient/Date Received:___________________________________________________________________

Interviewed (date and by whom):_____________________________________________________________________

References checked (dates and by whom):________________________________________________________________

Outcome: ______________________________________________________________________

Safe Child Policy Agreement

( ) I have been provided with, read and agree to abide by the Central Presbyterian Church Safe Child Policy Program Manual. I understand that the guidelines, policies and procedures contained therein are intended for the safety and protection of all the children, youth, employees, volunteers, and leaders involved in the programs and activities of Central Presbyterian Church.

Certification and Authorization for Release of Information (applicant must check one)

( ) I certify by my signature below that (i) I have never been convicted of or pled guilty to a felony; (ii) no civil, criminal, ecclesiastical complaint has been sustained* or is pending** against me for sexual misconduct or child abuse; and that I have never resigned or been terminated from a position for reasons related to sexual misconduct or child abuse.

By my signature below, I hereby certify and affirm that the information in this form is accurate to the best of my knowledge and may be verified by the assigned pastor of Central Presbyterian Church. I hereby authorize him/her to obtain a felony criminal history on me through the Indiana State Police, Central Repository. I further authorize him/her to inquire concerning any civil, criminal, judicial or ecclesiastical records or proceedings involving me as a defendant, related to felony convictions, sexual misconduct or child abuse. By means of this release, I also authorize any previous employer, and any law enforcement agencies or judicial authorities or ecclesiastical governing bodies to release any and all requested relevant information related to felony convictions, sexual misconduct or child abuse to the assigned pastor of Central Presbyterian Church.

By my signature below I further certify and affirm that I have read the above certification and release form and fully understand that the information obtained may be used to deny me appointment as an employee of Central Presbyterian Church. I also agree that I will hold harmless Central Presbyterian Church and its agents, employees, the employing or judicial authority or any other entity from any and all claims, liabilities, and causes of action for the legitimate release of any information related to sexual misconduct, child abuse or felony criminal history.

Signature Date

For purposes of this form, the term “pending” shall mean: (1) in a criminal court, “pending” means a criminal charge before a grand jury, in the process of being prosecuted, or in a case in which there is not yet a verdict; (2) in a civil court, “pending” means a case in which there has not been a decision or judgment; and (3) in an ecclesiastical case, “pending” means an accusation is being investigated by a special disciplinary committee or charges have been filed but have not yet been decided by a permanent judicial commission; or an accusation or charges are in an equivalent state or process in a church other that the PC (U.S.A.).

All persons who, for the first time, are applying and/or being considered for a volunteer position with Central Presbyterian Church that will require or result in frequent interaction with children or youth shall be required to complete this application. The application shall be submitted to the Staff member responsible for child and youth programming and/or a pastor.

Volunteer Name (first, middle, last): _______________________________________________

Phone (h):____________ Phone (w):____________ Fax:___________________ E-Mail:___________

d/o/b: _______________ Social Security No.: _____________ Drivers License No.: _____________

Position for which Volunteer is Applying: _______________________________________________

For Office Use Only:

SCOT Recipient/Date Received:___________________________________________________________________

Interviewed (date and by whom):_____________________________________________________________________

References checked (dates and by whom):________________________________________________________________

Outcome: ______________________________________________________________________

Certification and Authorization for Release of Information (applicant must check one)

By my signature below, I hereby certify and affirm that the information in this form is accurate to the best of my knowledge.

By my signature below I further certify and affirm that I have read the above certification form and fully understand that the information obtained may be used to deny me appointment as a volunteer of Central Presbyterian Church. I also agree that I will hold harmless Central Presbyterian Church and its agents, employees, the employing or judicial authority or any other entity from any and all claims, liabilities, and causes of action for the legitimate release of any information related to sexual misconduct, child abuse or felony criminal history.

Signature Date

APPENDIX 3

Name: ______________________________________________________________________________

Safe Child Policy Agreement

By my signature below, I hereby certify and affirm that the information in this form is accurate to the best of my knowledge.

Signature Date

1. In a criminal court “sustained” means that there has been a guilty plea, a guilty verdict or plea-bargain.

2. In a civil court, “sustained” means that there has been a judgment against the defendant.

3. In an ecclesiastical case, “sustained” means that there has been a guilty plea and censure imposed, or finding of guilty with censure imposed, by a permanent judicial commission in the Presbyterian Church (U.S.A.) or an equivalent body of another church.

1. In a criminal court, “pending” means a criminal charge before a grand jury, in the process of being prosecuted, or in a case in which there is not yet a verdict.

2. In a civil court, “pending” means a case in which there has not been a decision or judgment.

3. In an ecclesiastical case, “pending” means an accusation is being investigated by a special disciplinary committee or charges have been filed but have not yet been decided by a permanent judicial commission; or an accusation or charges are in an equivalent state or process in a church other that the PC (U.S.A.).

By your signature and initials below you are acknowledging and representing that you have received a copy of Central Presbyterian Church’s Safe Child Policy (“Policy”) and that you have read and understand the Policy. For purposes of this form the term “children” shall include all individuals under the age of eighteen (18).

Parents of children being served, ministers and administration/professional staff of the Church have the right to observe any activity or programs of Vacation Bible School (“VBS”) at any time. At no time will anyone working with children have a one-to-one meeting behind closed doors.

All staff and volunteers working with children during VBS must wear a nametag. All infants and children through kindergarten must wear a nametag. The class, program, or activity leader will keep attendance.

At least two (2) unrelated volunteers shall work together with children at all times. At no time shall less than (2) unrelated volunteers be alone with an unrelated child.

When a preschool child needs assistance using the bathroom, an adult may assist and must follow these guidelines: No person under fourteen (14) should help children unless accompanied by an adult; the bathroom door must be left open while the adult/assistant is present.

An adult should escort a group of elementary school-aged children to the restroom. Except in cases of emergency, volunteers shall avoid taking a child to the restroom alone. If it is necessary to take a child to the restroom alone, the volunteer shall observe the open door policy. If a child must be sent to the restroom alone, without an adult, the volunteer who sends the child to the restroom shall establish a short time frame for the child’s return.

Toddlers (18 mos to 4 yrs), 1 adult per 5 children; Pre-Kindergarten (4 to 6 years), 1 adult per 6 children.

No child should be left in a classroom or program area without the teacher or adult leader present.

Children will be released only to a parent, legal guardian, or authorized adult following VBS. Teachers/volunteers should not leave the program area until all children have been released appropriately. Parents may authorize their child to be released to another adult or family member. A parent or responsible adult must supervise children at all times. No child should be left unsupervised in the church buildings or on the church grounds.

Physical contact with children should be appropriate to their ages and development. Adults shall avoid initiating full contact, body-to-body hugs/kisses. Children five (5) years or younger may sit on an adult’s lap. Lap-sitting should be discouraged with school age children while youth (sixth grade and older) shall not be permitted to sit on an adult’s lap. Gentle contact during activities may occur in the form of pats on children’s backs, shoulders, arms or hands.

Discipline will be carried out through instruction, training, corrections and positive reinforcement. PHYSICAL PUNISHMENT AND HUMILIATION SHALL NEVER BE USED. The following steps should be followed upon observing inappropriate behavior:

4. physical contact should used only when absolutely necessary and shall be limited to gentle restraint;

7. for third offenses, the child should be removed from the activity and the parents of the child shall be contacted;

8. in extreme cases where the child becomes a threat to him/herself or others, remove the child from the room. Do not leave the child unattended; and

9. A pastor and/or the VBS program leader shall be contacted for any situation that cannot be handled in accordance with the above guidelines.

( ) I certify by my signature below that (i) I have never been convicted of or pled guilty to a felony; (ii) no civil, criminal, ecclesiastical complaint has been sustained* or is pending against me for sexual misconduct or child abuse; and that I have never resigned or been terminated from a position for reasons related to sexual misconduct or child abuse.

By my signature below, I hereby certify and affirm that the information in this form is accurate to the best of my knowledge. By my signature below I further certify and affirm that I have read the above certification form and fully understand that the information obtained may be used to deny me appointment as a volunteer or servant of Central Presbyterian Church.

Signature Date

For purposes of this form, the term “sustained” shall mean: (1) in a criminal court “sustained” means that there has been a guilty plea, a guilty verdict or plea-bargain; (2) in a civil court, “sustained” means that there has been a judgment against the defendant; and (3) in an ecclesiastical case, “sustained” means that there has been a guilty plea and censure imposed, or finding of guilty with censure imposed, by a permanent judicial commission in the Presbyterian Church (U.S.A.) or an equivalent body of another church. For purposes of this form, the term “pending” shall mean: (1) in a criminal court, “pending” means a criminal charge before a grand jury, in the process of being prosecuted, or in a case in which there is not yet a verdict; (2) in a civil court, “pending” means a case in which there has not been a decision or judgment; and (3) in an ecclesiastical case, “pending” means an accusation is being investigated by a special disciplinary committee or charges have been filed but have not yet been decided by a permanent judicial commission; or an accusation or charges are in an equivalent state or process in a church other that the PC (U.S.A.).

Name(s) of Parent(s)/Guardian(s): ____________________________________________________

Parent(s)/Guardian(s) Address: ____________________________________________________

Programs for which you wish to register this child/youth [check all that apply]:

Please list anything special about your child or youth that you would like us to know, (e.g., custodial arrangements, persons to whom your child should not be released) _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

I hereby grant to Central Presbyterian Church (“Church”) the right and permission to use any photographs or video it has taken of my child or youth named above for any purpose relating to Church related activities, programs, or events depicted in media produced, published, or distributed by the Church now or in the future. I hereby release and discharge Church from any and all claims and demands arising out of or in connection with the use of the photographs or videos, including any and all claims for libel or invasion of privacy.

Other Health Issues: _________________________________________________________________

Prescriptions/reason: _________________________________________________________________

Child’s Primary Physician: __________________________ Telephone No: _________________

Health Insurance Carrier: ___________________________ Policy No.:____________________

Child’s Dentist: __________________________________ Telephone No:_________________

Dental Insurance Carrier: __________________________ Policy No.:____________________

Parents are responsible for updating the information in this form as appropriate.

The undersigned hereby agree and consent to the administration of over-the-counter medicines (e.g., Tylenol, Pepto-Bismol) to the above named child or youth for minor ailments. In case of emergency, I (we) authorize the adult in charge to consent to medical care, or dental care, or both, for my/our minor child. For purposes of this consent, the term “medical care” shall include, but not be limited to, X-ray examination, anesthetic, medical or surgical diagnosis or treatment, and hospital care under the general or special supervision and upon the advice of or to be rendered by a licensed physician or surgeon. For purposes of this consent, the term “dental care” shall include, by not be limited to, X-ray examination, anesthetic, dental or surgical diagnosis or treatment, and hospital care by a licensed dentist. I (We) further hereby authorize any and all of my child’s health care providers to release and/or disclose any and all protected health information relevant to the diagnosis and treatment of any physical, mental, and/or emotional condition of my child to the adult in charge. This Authorization shall extend to and include, but not be limited to my child’s medical history, including specific progress notes regarding any problems that would impact any surgery or procedures, progress or outcome, results of relevant diagnostic or laboratory tests, and, where necessary, my child’s entire medical record. I/We understand that information used or disclosed pursuant to this consent may be subject to re-disclosure by the above named person and may no longer be protected by federal or state law. I/We understand that information used or disclosed pursuant to this consent may be subject to re-disclosure by the above named person and may no longer be protected by federal or state law.

Central Presbyterian Church uses a blanket permission slip for off-campus activities for each Church School year. This policy applies to all children and youth in grades three through twelve. This form, along with an annual Consent to Medical Treatment form must be on file for your child or youth to be included in any such events.

I hereby give permission for my child, _______________________________, to participate with the Central Presbyterian Church children or youth groups, at any and all of-campus, church approved events beginning __________________ and extending to ______________. I will notify the specific group leaders if my child does not have permission to attend a specific event. I have completed the annual Consent to Medical Treatment form and it is on file in the church office. I accept responsibility for payment of any and all expenses required for a specific local, off-site event.

In signing this form I understand that I will hold neither the supervisory adults nor Central Presbyterian Church or any of its agents liable for injuries or damages sustained by my child/youth during any off-campus, church-sponsored event.

A SEPARATE PERMISSION FORM SHALL BE REQUIRED FOR ANY OVERNIGHT TRIP OR EVENT AND ANY EVENT OR TRIP THAT REQUIRES TRANSPORTATION TO A SITE OUTSIDE OF TIPPECANOE COUNTY, INDIANA.

This form must be filled out by the leader-in-charge every time a group of Children or Youth leaves the Central Presbyterian Church complex by means of a vehicle. Where possible, this form shall be submitted to the Associate Pastor and/or the Safe Child Oversight Team at least three (3) weeks prior to the event.

Name of Group: _____________________________________________________________________________________

Destination: _____________________________________________________________________________________

_____________________________________________________________________________________

Date/Time Leaving: ___________________ Date/Time Returning: ____________________

Adult(s) in Charge:

_________________________________ _________________________________

[Name] [Name]

_________________________________ _________________________________

Other Adult(s) attending:

_________________________________ _________________________________

[Name] [Name]

_________________________________ _________________________________

Purpose of the Trip:____________________________________________________________________

_____________________________________________________________________________________

2. The names of all adults who will be driving to and/or from the program, event, or field trip and the model, make, color, and year of the vehicle to be driven;

3. A list of the Children and/or Youth attending with completed permission forms for each participant.

THIS FORM WILL NOT BE APPROVED UNLESS IT IS COMPLETED IN ITS ENTIRETY AND IS ACCOMPANIED BY THE DOCUMENTS LISTED ABOVE.

I hereby give permission for my child, ______________________________________________, to participate in the _____________________________________________ [name of the event] sponsored by Central Presbyterian Church of Lafayette, Indiana.

It is my understanding that the event will be held on ______________from_______ to ____________ [time and dates]. The location of the event will be _________________________________________, which will be reached by __________________________ [mode of transportation].

I have completed all forms required by the leaders of the event including, but not limited to, a medical release form for my child. I have also read all of the information with regard to itinerary, schedule and group rules.

For Office Use Only:

Date Received__________

Office Communication ___________________________________________________________________________

Staff Signature______________________________________________________________

Name of Child/Youth: _________________________________________________________________

Group/Activity Child/Youth participating in: _______________________________________________

Date/Time/Location/Description of Accident/Incident: ________________________________________

_____________________________________________________________________________________

Description of Action Taken, and by whom: _________________________________________________

_____________________________________________________________________________________

Action Taken in Response to Report:_______________________________________________________

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

APPENDIX 1

Safe Child Policy Agreement

Signature Date

Signature Date

APPENDIX 3

Safe Child Policy Agreement

Signature Date

Signature Date

Health Insurance Carrier: _______ Policy No.:

Child’s Dentist: __________________ Telephone No:_

Adult(s) in Charge:

_ _

[Name] [Name]

_ _

Other Adult(s) attending:

_ _

[Name] [Name]

_ _