CONFIRMATION OF AGREEMENT TO ABIDE BY Safe Child POLICY

 Name (please print):

             _________________________________________________________________________

                                    LAST                           First                              Middle

 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 (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.

OR

(   )       I am unable to make the above certification.

 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 an employee, 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.

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.

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.).