PROTECTION PLAN
For Ministry To Children, Youth and Special Needs Adults

Safeguards for Reducing the Risk

"For you were once darkness, but not you are light in the Lord. Live as children of light (for the fruit of the light consists in all goodness, righteousness and truth) and find out what pleases the Lord. Have nothing to do with the fruitless deeds of darkness, but rather expose them."

Ephesians 5:8-11

Forest Lakes Christian Education Commission
Table of Contents

A. Forward 1

B. Getting Started 2

C. Our Purpose 3

D. The Protection Plan 4-5
1. Prevention of Abuse
2. Recognition of Abuse
3. Reporting of Abuse

E. Protection Plan for Children and Youth 6-7

F. Protection Plan for Special Needs Ministry 8

G. Appendix A: Signs of Sexual Abuse, Physical Abuse and Neglect 9-11

H. Appendix B: Facts and Quotes on Abuse 12-13

I. Appendix C: Safety Tips for Preventing Abuse 14

J. Appendix D: Additional Resources for Further Information 15

K. Forms:
1. Incident Report
2. Application for Children's, Youth, and Special Needs Ministry Workers
3. Primary Screening Form (another option)
4. Screening Reference Form
5. Chrurch Activity Requisition
6. Church Activity Permission Form
7. Transportation Approval
8. WI Criminal History Multiple Name Record Request

The Christian Education Commission of the Forest Lakes District is grateful to the Evangelical Free Church of Sheboygan, WI to use materials in their Protection Plan, copyright date 1997, for this publication. While this material has been reviewed by legal council, it would still be necessary for the leadership of your church and your legal counselor to review this document before adopting.

If your church does not have a Protection Plan in place, please use this as a guide in adopting a policy that is suited for your church.

L. Forward

Every church must take direct responsibility to reduce the risk of child sexual abuse within its programs. Child sexual abuse is a problem that will not go away. The nightmare of abuse can only be dispelled if your church challenges it head-on through an effectively managed risk reduction program. It is no longer a question of, will you do it, the question is when? And the time to begin the process is now.

This policy has been designed to assist your church in developing an effective education program to undergird your risk reduction efforts. An effective education program must be intentional, comprehensive and sustained.

Important in this process is to educate church leaders and constituents as to the value of change before changing structure. Because this is such an emotionally charged issue, change will not come easily. Many things will be done differently than they were in the past. Some workers will respond saying, "I've worked with children for 25 years and now you're saying you need for me to fill out an application, submit references and do a background check. You don't trust me?! Forget it!"

The strategy must include educating and training church members/attenders to alleviate much of the stress involved in change. In fact, the effectiveness of your child abuse risk education program will be proportionate to the impact of your educational strategy. Helpful in understanding sexual abuse is material in Appendices A-D.

M. Getting Started

Child sexual abuse strikes children from every social background, race, and age. Often it occurs in settings where children or youth completely trust adults - homes, schools, camps, athletic and park programs, and most sadly, the church.

This sexual abuse can happen in any church - including yours. A profound legal and moral obligation exists to reduce the possibility of child sexual abuse from ever occurring. The purpose of this proposal is to help you make your church a safer place.

A Call to Church Leaders and Church Members/Attenders

The following proposal provides three steps to be taken to address the educational objectives of being intentional, comprehensive, and sustained.

1. Gain the support of key church leaders (Elders/Deacons) at to the potential risk sexual abuse presents to the church and the benefits of a risk reduction program. See Figure 1.

(Figure 1)

Using the model above... educate church leaders (Elders/Deacons) as to the potential risk sexual abuse presents to the church and the benefits of a risk reduction program. Demonstrate the need using the video tape ("Reducing The Risk...") and Moody Monthly articles listed below. In conjunction with Appendices A-D and the video tape, prepare a preliminary proposal of steps the church would need to take.

T Church Ministry Resources provides an excellent resource kit, "Reducing the Risk of Sexual Abuse in Your Church". This kit includes everything you need for the development of abuse prevention policies, as well as, for training. The 2-part video will be particularly helpful to introduce the need for an abuse prevention policy. Cost approximately $50.

T Moody Monthly published four excellent articles several years ago that contain some very useful information. The titles are: "An Uncertain Journey", "Discovering Sexual Abuse", "How You Can Help" and "Wrongly Accused." These articles are included as Appendix D.

N. Our Purpose

1. Why do we need this plan?

The main objective of our Protection Plan is to provide a safe and secure environment for those under our care. Abuse often occurs in settings - home, school, camp, and even church - where a child, youth or special needs adult completely trusts an individual.

Abuse robs children of their childhood and can potentially scar its young victims for life. Too often in the past, the effects of abuse were minimized or dismissed. Children were viewed as being resilient. Research has shown that children can suffer significant pain from even a single abuse incident. The church must be aware of the pain and long term suffering that can accompany such abuse.

2. What is the plan?

Our plan involves taking measures to prevent abuse and to protect from false allegations those responsible for the care of others. The Protection Plan includes:

a. Volunteers for children's and youth ministries must have attended your church for at least 6 months. The only exceptions to this requirement are:
$ Volunteers who come to your church from other Christian organizations with appropriate references and approval of the Children's Ministry Director or Senior Pastor.
$ Volunteers who provide a letter of reference from the pastor of their last church and who have met all the other requirements may be considered at the discretion of the Children's Ministry Director/Senior Pastor.

b. The screening of all ministry workers and paid employees who teach, help or care for children, youth and/or special needs adults.

c. The screening process requires the applicant to complete an application form, reference information, background check, have a confidential interview. The application, reference information and background checks will be required by most churches.

d. No person who has been previously convicted of abusive behavior will be allowed to work in the children's, youth and special needs ministries of the church.

e. All applicants are expected to be aware of methods to prevent, recognize and report abuse. Information pertaining to this can be read in this handbook and by obtaining additional resources. Please see Appendix D for a recommended list of resources.

f. Guidelines have been itemized for ministry to children, youth and special needs adults. These specific rules need to be carefully and faithfully followed.
D. The Protection Plan

The three parts of the Protection Plan are prevention, recognition and reporting of abuse.

1. Prevention

Prevention is the best defense for reducing the risk of any type of abuse in the Christian Education ministry. Main focus areas include:

a. The screening process requires an individual to complete the confidential Application for Children's, Youth and Special Needs Ministry Workers. Personal references will then be contacted, and a criminal background check will be done. An interview with a Screening Panel may be requested in instances where more information is needed.

b. All Christian Education workers are required to follow the Protection Guidelines.

c. Education aids in informing the Christian Education Staff of the sad reality of abuse and the necessity of each individual to protect and watch over the individuals under their care. Please refer to Appendix A to study the different forms of abuse, neglect and their symptoms.

2. Recognition of Abuse

Most cases of sexual abuse go undetected. There may be no apparent physical signs, or there may be physical signs detected only through medical examination.

The cases that are reported are generally reported by abused children to their parents, siblings or other "caretakers" - often in the form of casual remarks that lead the listener to query deeper.

But most children say nothing. They may not realize what was done to them was wrong. Often, they may be too embarrassed or frightened to speak up. And they may not want to get the offender in trouble - especially if a "friendship" has developed between the offender and victim, or the offender has threatened to harm them or a member or their family if they say anything.

In some cases, there are "telltale" physical or emotional signs that may arouse your suspicion. (Safety Tips on a Sensitive Subject: Child Sexual Abuse, (Appendicies C,D).
3. Reporting

What should be reported? Anything you see or hear from an individual that causes you to be concerned for the welfare of a child, youth or special needs adult.

Who should report? You should! If you know or suspect any form of abuse, promptly notify the person above you in the chain of command and complete an Incident Report. Persons who report in good faith are immune from civil or criminal liability.

What if you're wrong? You have not intentionally harmed anyone. Your motive was to protect the individual.

What if you're right and don't report it? In all likelihood, the abuse will continue when it could have been stopped by you.

If an allegation is made by an individual, please do the following:

1. React calmly. Be a source of stability and sensible reaction for the individual, his or her family, and others involved in the situation.
2. Reassure the person. The individual needs to know that he or she was right to inform you about the situation.
3. Avoid interrogation: leave the in-depth investigation and questioning to the proper authorities.
4. Treat the accused with dignity and support. (If the accused is a church worker, that person may be temporarily relieved of his or her duties until the investigation is finished.)
5. Report the suspected abuse to your immediate supervisor at church.
6. Only share information regarding the accusation with those in church leadership or the authorities handling the case. Confidentiality is very important!
7. Complete an Incident Report following any accusation of abuse and submit it to the Director of Christian Education. Document all your efforts in handling the incident!
8. You should not inform the abused person or the alleged abuser that you are making a report.
9. Only the church's designated spokesperson will speak to the news media (printed or TV) using the text of a prepared public statement approved by the Elders of the church. All volunteers and members are asked to refer all questions to the designated spokesperson. Do not reveal any names.
E. Protection Plan for Children and Youth

1. There must be at least two (2) approved adult workers* in the room and/or group of children for babies and toddlers through kindergarten.

2. There must be a least one (1) approved adult worker* per room and/or group of children in grades 1-6.

3. Approved personnel will be present at least ten (10) minutes before, during and after events, until the last child has left the premises.

4. One or more supervisors will circulate among rooms when children's activities are being held.

5. Only those 18 years of age or older may change diapers or assist children with using the restroom.

6. Children in preschool through grade 4 shall not be allowed to go to the restroom without adult supervision.

7. Children should not be left alone to wander the halls or go to other areas of the church unsupervised.

8. When a parent or guardian has to be called out of a service to attend to a child, an usher or supervisor (if possible) should contact the parent. If there are more that two (2) adult workers in the room, then a children's worker may leave the room to locate the parent or guardian. This way one worker is not left alone while the other goes to get the parent or guardian.

9. Only parents, guardians and other adults with the proper identification tags may pick up children. Exceptions to this policy will be made by written consent from the parents/guardians of the preschool child.

10. Window blinds are to remain open or up at all times. Windows in classroom doors should remain uncovered.

11. An emergency evacuation diagram will be clearly posted in every preschool room and elementary department. Workers are to guide children as a group to the designated safe area(s).

12. Christian Education staff should not be alone with a child while car pooling. If this is not possible, written parental/guardian permission should be sought before transporting the child. Verbal permission may be obtained via phone call and must be documented.
13. Any ministry worker who has concerns about the safety, welfare or health of the children being cared for in your church you should immediately notify the Department Coordinator, AWANA Commander or Director of Christian Education and complete an Incident Report. All such reports will be followed up. Persons who report in good faith are immune from civil or criminal liability.

* An approved adult worker is a person, 18 years or older, who has gone through the prescribed screening process in your church.
F. Protection Plan for Special Needs Ministry

1. At least two (2) approved adult workers* should be present at all times for the activities of special needs individuals.

2. Approved personnel will be present at least ten (10) minutes before, during and after events, until the last special needs individual has left the premises.

3. In order for an outside activity conducted off church premises to be sanctioned by the church, you must have a written approval from your ministry leader (Department Coordinator or the Director of Christian Education). Each parent or guardian should complete a Church Activity Form. All such activities must be supervised by approved by adult workers*.

4. Staff should not be alone with a special needs individual while car pooling. If this is not possible, written parental/guardian permission should be sought before transporting the individual.

5. For overnight activities, all adult chaperons and supervisors must be cleared in advance with the Director of Christian Education to stay with special needs adults.

6. Windows in classroom doors should remain uncovered.

7. An emergency evacuation diagram will be clearly posted in every department. Workers are to guide the special needs individuals as a group to the designated safe area(s).

8. Any ministry worker who has concerns about the safety, welfare or health of the special needs individuals being cared for in your church should immediately notify the Director of Christian Education and complete an Incident Report. All such reports will be followed up. Persons who report in good faith are immune from civil or criminal liability.

* An approved adult worker is a person, 18 years or older, who has gone through the prescribed screening process.
G. APPENDIX A: Signs of Sexual, Physical Abuse, and Neglect

Following are the major signs of sexual abuse, physical abuse and neglect. One of these, or even several in combination, may not indicate that abuse has occurred. They may indicate accidents or that other medical conditions, emotional illness, or problems exist. If a number of these signs occur together or if they reoccur frequently, child abuse and neglect may be suspected. (WI Dept. of Health and Social Services, PSC-101.)

1. Sexual Abuse

Sexual abuse is any sexual exploitation of a minor or special needs adult. It may be violent or nonviolent. All sexual abuse is an exploitation of an individual's vulnerability and powerlessness, and the abuser is fully responsible for the actions. Sexual abuse of minors or special needs adults is criminal behavior that involves an individual in sexual behaviors for which he/she is not personally, socially or developmentally ready.

But among you their must not be even a hint of sexual immorality, or of any kind of impurity, or of greed, because these are improper for God's holy people. (Ephesisns 5:3)

a. Types of Sexual Abuse

(1) Touch

(a) Fondling
(b) Oral, genital or anal stimulation/penetration
(c) Intercourse
(d) Incest
(e) Forcible rape

(2) Non-Touching

(a) Inappropriate verbal comments)
(b) Pornographic media
(c) Obscene phone calls
(d) Exhibitionism
(e) "Peeping"
(f) Causing or allowing children to witness sexual activity

b. Physical signs MAY include:

(1) Pain, swelling or itching in genital and/or anal areas
(2) Bruises, bleeding, discharge in genital and/or anal areas
(3) Difficulty walking or sitting, frequent urination, pain
(4) Torn, stained or bloody underclothing
(5) Sexually-transmitted diseases
(6) Pregnancy
c. Behavioral signs MAY include:

(1) Anxiety when approaching place of abuse (home, church, school, etc.)
(2) (Sudden) nervous or hostile behavior toward adults
(3) (Sudden) sexual self-consciousness
(4) "Acting out" of sexual behavior
(5) Withdrawal from church activities and friends
(6) Verbal indicators of not wanting to be with someone or reports of being abused
(7) Unusual interest in sex for age
(8) Regressive or childlike behavior inappropriate for age
(9) Excessive masturbation
(10) Recurring nightmares
(11) Runaway or delinquent
(12) Alcohol/drug abuse

2. Physical Abuse

Physical abuse is any physical injury inflicted on a child, youth, or special needs adult by other than accidental means. This physical injury includes, but is not limited to, lacerations, fractured bones, burns, internal injuries, severe or frequent bruising or great bodily harm.

"Get rid of all bitterness, rage and anger, brawling and slander, along with every form of malice. Be kind and compassionate to one another, forgiving each other, just as in Christ, God forgave you." (Ephesians 4:31-32)

A. Physical signs MAY include:

(1) Bruises, welts on face, neck, chest, back, etc.
(2) Injuries in the shape of object (belt, chord)
(3) Unexplained burns on palms, soles, back
(4) Fractures that do not fit story of injury

B. Behavioral signs MAY include:

(1) Delay in seeking medical help
(2) Extremes in behavior: very aggressive or withdrawn and shy
(3) Afraid to go home
(4) Frightened of parents
(5) Fearful of other adults

3. Neglect

Neglect is demonstrated when a parent, guardian or caretaker willfully fails to provide for emotional (love, attention, etc.) or physical needs (food, clothing, shelter, etc.) and/or fails to offer guidance and supervision of a child, youth or special needs adult.
"But if anyone does not provide for his relatives, and especially for those of his immediate family, he has denied the faith, and is worse than an unbeliever." (I Timothy 5:8)

A. Physical signs MAY include:

(1) Poor hygiene, odor
(2) Inappropriately dressed for weather
(3) Needs medical or dental care, glasses or hearing aid
(4) Consistent hunger, looks under-nourished
(5) Left alone, unsupervised for long periods

B. Behavioral signs MAY include:

(1) Extreme willingness to please
(2) Constantly falling asleep in class
(3) Craves attention from adults
(4) Aggressive behavior
H. APPENDIX B: Facts and Quotes on Abuse

Current conservative estimates suggest that from 500,000 children are sexually abused each year. (Reducing the Risk of Child Sexual Abuse In Your Church, 1993)

The first national study on the prevalence of child sexual abuse found that 27% of the women and 16% of the men in the sample had experienced child sexual victimization. Over 25% of these were victimized before the age of 9. The true extent of sexual abuse is unknown. (David Finkelhor, A Sourcebook on Child Sexual Abuse, 1986)

Reported victims have been as young as six months old, but the incidence of abuse peaks between 7 and 13 years. (D. Finkelhor, "Answers to Important Questions about the Scope and Nature of Child Sexual Abuse," in The Future of Children, Volume 4, No. 2, 1994)

Most children are abused by someone they know. Strangers account for less than 20% of abusers. This means that in over 80% of the child sexual abuse cases, the abuser is someone who is known (and often trusted) by the child. (Caren Adams and Jennifer Fay, No More Secrets: Protecting Your Child From Sexual Assault, 1991)

Most sexual offenders are male. One in four offenders is a member of the child's family or a person who has been entrusted with the care of the child. Approximately half are friends of the child or family. (Child Sexual Abuse: Guidelines for Community Workers, p. 23)

As much as 56% of reported child molestation cases are committed by adolescents, mostly male. (Roger Katz, "Psychosocial adjustment in Adolescent Child Molesters" In Child Abuse and Neglect, Vol. 14, 1990)

Child molesters can be classified as either preferential or situational. Preferential molesters have a preference for sexual activity with children and will seek them out. Situational molesters do not, but take advantage of a situation to sexually abuse children if it occurs. Sexual abuse may range from a once-in-a-lifetime act to a long-term pattern of behavior. Most offenders are situational and that number is increasing faster than those of preferential child molesters. (Breach of Trust, D-2)

Over three million children suffer from physical, sexual or emotional abuse and neglect each year in the United States. (For the Love of Children, National Committee to Prevent Child Abuse)

Approximately three children a day die as a result of abuse and neglect. (Lung, C.T. and Daro, D., Current Trends in Child Abuse Reporting and Fatalities: The Results of the 1995 Annual Fifty State Survey, 1996))

Among the children for whom maltreatment was substantiated or indicated in 1994, about 53% suffered neglect, 26% physical abuse, 14% sexual abuse, 5% emotional abuse, 3% medical neglect, and 19% other forms of maltreatment. Some children were victims of more than one type of maltreatment. (U.S. Department of Health and Humans Services, HHS Fact Sheet, "Preliminary Findings Regarding Child Abuse and Neglect," released December 7, 1995)
The effects of child abuse can be many and long lasting. Many abused children grow up to abuse their own children. Also, childhood histories of abuse and neglect are commonly reported by many adult criminals, juvenile delinquents and teenage drug addicts and prostitutes. (For the Love of Children, National Committee to Prevent Child Abuse)

Child abuse can be treated and prevented. (For the Love of Children, National Committee to Prevent Child Abuse)

Approximately two out of three molesters who are caught will sexually abuse again in the future. (Church Law and Tax Report, Klipowicz, 1993)

1. Who are the abusers?

The following is a list of common characteristics of the sexual abuser. It is not meant to be an all inclusive list.

A. The vast majority of perpetrators are members of the child's family.
B. Over 80% of the time the abuser is someone known to the victim.
C. Most abuse takes place within the context of an ongoing relationship (parent/child, step-parent/child, teacher/student, grandparent/grandchild, etc.)
D. 20% of sex offenders begin their activity before the age of 18.
E. The vast majority of child perpetrators are teenage or adult males. Most are heterosexual men, many with children and a wife or girlfriend. Perpetrators come from all age groups, demographic, socio-economic levels, religions, racial and ethnic backgrounds.

2. Who are the victims?

A. The person abused
B. The victim's family
C. The church body
D. The family of the accused
E. Society

Because it is often impossible to tell who is a sex offender until he or she abuses someone, the best strategy for prevention is to prepare an individual so they won't be victims. Please refer to Appendix C: Safety Tips for Preventing Abuse and Appendix D: Additional Resources for Further Information.
I. APPENDIX C: Safety Tips for Preventing Abuse

1. Appropriate Behavior*

A. Giving a short hug or putting comforting arm around child
B. Physically restraining a child from hurting self or others
C. Meeting in public places when doing one-on-ones with someone

2. Inappropriate Behavior*

A. Long embraces, sexual kissing, touching private areas, self exposure
B. Hitting, slapping, spanking, shaking, squeezing or biting
C. Verbally degrading or humiliating

3. Potential Inappropriate Behavior*

A. Back rubs
B. Tickling
C. Wrestling
D. Slapping on the buttocks

* These lists of appropriate, inappropriate and potential inappropriate behaviors show examples of these types of behaviors, but are not limited to those listed.

"If you have any encouragement from being united with Christ, if any comfort from His love, if any fellowship with the spirit, if any tenderness and compassion, then make may joy complete by being like-minded, having the same love, being one in spirit and purpose…each of you should look not only to your own interests, but also to the interests of others." (Phillipians 2:1-2,4)
J. APPENDIX D: Additional Resources for Further Information

Reducing the Risk of Child Sexual Abuse in Your Church - video - (highly recommended to help understand why a church needs to have a Protection Plan).

Somebody Told - video - (highly recommended in training staff to prevent child sexual abuse). Produced by VideoNet.

When Child Abuse Comes to the Church by Bill Anderson (practical guidebook for prevention, detection and response); Bethany House Publishers, 1992.

When Trust is Lost - pamphlet by Dan Allender, Discovery Series, Radio Bible Class, Grand Rapids, MI 49555, 1992.

The Wounded Heart by Dan Allender, NavPress, 1990. (Outstanding book and workbook for counselors and adult victims of childhood sexual abuse).

Child Protection pamphlet, National Center for Mission and Exploited Children, Arlington VA. (Excellent resource for parents to help prevent their children from becoming abused).

National Committee to Prevent Child Abuse, 332 Michigan Avenue, suite 1600, Chicago, IL 60604-4357, Phone (312) 663-3520. Visit their Web Site at http://www. childabuse.org.

Moody Monthly Articles

Agencies -
Church Mutual
Church Tax Law and Report

K. Forms

1. Incident Report
2. Application for Children's, Youth and Special Needs Ministry Workers (2 different forms).
3. Screening Reference Form
4. Church Activity Requisition
5. Church Activity Permission Form
6. Transportation Approval
7. Multiple Name Record Request Form

INCIDENT REPORT

This form is to be used for reporting incidents of observation, allegations, or reasonable suspicions of abuse or injury to a child, youth, or special needs adult while under the care or supervision of (Organization Name) staff or its volunteers. The completed Incident Report should be submitted to the Directory of Christian Education.

Type of report: G Observation G Allegation G Suspicion

Type of incident (check as many as apply): G Physical Injury G Sexual Abuse G Physical Abuse G Other

Name of Minor/Special Needs Adult: Birth date:

Address:

City: State: Zip Code:

DETAILS OF INCIDENT

Date of incident: Time of incident: a.m. / p.m.

Place of incident:

Description of incident (use additional sheet if necessary):

If known, name of suspected abuser:

Were other adults or minors involved? G Yes G No If yes, who?

Persons notified or aware of incident: (please specify all names, date and time)

G Parents/Guardians: When?

G Church Staff: When?

G Dept. of Social Services: When?

G Other: When?

Was there medical treatment? G Yes G No If yes, please specify the following:

Doctor's name:

Injuries claimed:

Where was injured taken? (Name of facility)

~ FOR CHURCH USE ONLY ~

DEPARTMENT/MINISTRY COORDINATOR

Received report on

Received report from

Notified on

How was notification given?

What follow-up was done based on this report?

What is the status of the worker?

APPLICATION FOR CHILDREN'S, YOUTH AND SPECIAL NEEDS MINISTRY WORKERS

~ CONFIDENTIAL ~

This application is to be completed by all applicants for any position involving the supervision or custody of minors or special needs adults. This is not an employment application form. Persons seeking a position in the church as a paid employee will be required to complete an application in addition to this screening form. It is being used to help the church provide a safe and secure environment for those children, youth and special needs adults who participate in our programs and use our facilities.

GENERAL INFORMATION

Name Spouse's Name

Address City State Zip

Home Phone ( _____ ) Work Phone ( _____ )

BACKGROUND INFORMATION

Do you regularly attend our Worship Services? G Yes G No If yes, since when: Month _____________ Year _____________

Do you regularly attend adult Sunday School? G Yes G No If yes, since when: Month _____________ Year _____________

In what church activities are you presently involved?

In what areas of church ministry are you currently serving?

Have you personally accepted Jesus Christ as your Lord and Savior and are you committed to having the character of Jesus live through you? G Yes G No

Tell us about your spiritual journey to date:

I have chosen to work with children/youth/special needs adults at (Organization Name) Because…

If there has been alcohol abuse, drug abuse, physical or sexual abuse in your family background, what steps have you taken to
minimize the impact that those issues may create for you, both now and in the future?

REFERENCES

List three (3) people you have know for at least (1) year, who are not related to you and have a definite knowledge of your character and ability to work with people.

1. Church Staff, Small Group or Ministry Leader

Name Nature of Association

Occupation Length of Time Known

Address City State Zip

Home Phone ( ____ ) Work Phone ( ____ )

2. Employer, Work-Related Acquaintance, Former Teacher or Ministry Co-Worker

Name Nature of Association

Occupation Length of Time Known

Address City State Zip

Home Phone ( ____ ) Work Phone ( ____ )

3. Social Friend or Neighbor

Name Nature of Association

Occupation Length of Time Known

Address City State Zip

Home Phone ( ____ ) Work Phone ( ____ )

PREVIOUS ADDRESS

If you have lived at your current address for less than seven (7) years, provide information on all addresses during that period.

Address City State Zip

From: _____ / _____ / _____ to _____ / _____ / _____

Address City State Zip

From: _____ / _____ / _____ to _____ / _____ / _____

Address City State Zip

From: _____ / _____ / _____ to _____ / _____ / _____
EMPLOYMENT HISTORY

Present Employer Supervisor

Address City State Zip

Position(s) held G Full-Time G Part-Time

Employment dates: Starting: _____ / _____ / _____

If you have been employed at this position for less than two (2) years, provide information on your previous employment below.

Previous Employer Supervisor

Address City State Zip

Position(s) held G Full-Time G Part-Time

Employment dates: Starting: _____ / _____ / _____ Ending: _____ / _____ / _____

MILITARY SERVICE

Branch Enlist Date _____ / _____ / _____ Discharge Date _____ / _____ / _____

PERSONAL SITUATIONS

Are you… G Single G Married G Widowed G Divorced G Separated
Do you have children of your own? G Yes G No

Have you ever been arrested, convicted or pleaded guilty to a crime? G Yes G No If yes, please explain.

Have you ever been accused, charged, or alleged to have, or have you ever committed any act of neglecting, abusing or molesting any
child, youth or special needs adult? G Yes G No If yes, please explain.

Do you have a history of any contagious disease, health issue or emotional illness that would currently place minors, special needs adults, other workers or you at risk? G Yes G No If yes, please explain.

Have you ever been concerned that you may have an addiction to drugs, alcohol, pornography or any other addiction; or has anyone ever suggested that you may have a problem with any of the above? G Yes G No If yes, please explain.

Is there any circumstance or pattern in your life which would make it inappropriate for you to serve with minors or special needs adults, or would compromise the integrity of (Organization Name) ? G Yes G No If yes, please explain.

CHURCH HISTORY AND PRIOR YOUTH WORK
Are you a member of (Organization Name) ? G Yes G No
If no, name of church of which you are a member or affiliated:
List name and address of other church(es) you have attended regularly during the past five (5) years:

List all previous church work involving children/youth/special needs adults (list each church's name and address, type of work performed and dates). Use additional sheet, if necessary:

List all previous non-church work involving children/youth/special needs adults (list each organization's name and address, type of work performed and dates). Use additional sheet, if necessary:

APPLICANT'S STATEMENT

The information contained in this application is correct to the best of my knowledge. I authorize any references or churches listed in this application to give you any information (including opinions) that they have regarding my character and fitness for work with children, youth or special needs adults. I hereby release (Organization Name) and its officers, employees, volunteers, and other agents from any and all liability for damages of whatever kind or nature which may at any time result to me, my heirs, or family resulting from (Organization Name) 's investigation of and action upon this application. I reserve the right to meet with To discuss information gathered in response to my application, either from persons or organizations, whether or not previously identified by me as potential sources of information.

I have received and reviewed a copy of the Protection Plan for Ministry to Children, Youth and Special Needs Adults and agree to abide by it. I understand that if I have questions, I should contact the Director of Christian Education.

Should my application be accepted, I agree to refrain from unscriptural conduct (as outlined in the Christian Education Workers Covenant) in the performance of my services on behalf of the church.

I further state that I HAVE CAREFULLY READ THE FOREGOING RELEASE AND KNOW THE CONTENTS THEREOF AND SIGN THIS RELEASE AS MY OWN FREE ACT. This is a legally binding agreement which I have read and understand.

Applicant's Signature Date

Witness Date

REQUEST FOR CRIMINAL RECORDS CHECK AND AUTHORIZATION

I hereby request and authorize the release of any information which pertains to any record of convictions contained in law enforcement files or in any criminal file maintained on me whether local, state, or national. I hereby release local, state, and national law enforcement agencies from any and all liability resulting from such disclosure.

Signature Date

Print Name Print Maiden Name (if applicable)

Print All Aliases

Date of Birth _____ / _____ / _____ Place of Birth

* Driver's License Number and State Social Security Number

* Identity must be confirmed with a state driver's license or other photographic identification.
~ a copy of this ED should be attached to this application form ~

OFFICE USE ONLY

Entered References

Interview Confirmation

Denied because:

Approved: 11-22-94 PRIMARY SCREENING

Redeemer Evangelical Free Church
7735 W. Howard Avenue o P.O. Box 20864
Milwaukee, WI 53220

This application is to be completed by all applicants for any position (volunteer or compensated involving the supervision or custody of minors. This is not an employment application form. Persons seeking a position in the church as a paid employee will be required to complete an employment application in addition to this screening form. It is being used to help the church provide a safe and secure environment for those children and youth who participate in our programs and use our facilities.

PERSONAL

Name Date of Birth
Last First Middle (Maiden)

Identity must be confirmed with a state drivers license or other photographic identification.

Present address:

City State Zip Home phone ( )

Please indicate the type of youth or children's work you prefer

Please indicate the date you would be available to begin

What is the minimum length of commitment you can make?

Have you ever been convicted of or pleaded guilty to a crime? _______ YES _______ NO

If yes, please explain - attach a separate page, if necessary

Where you a victim of abuse or molestation while a minor? _______ YES _______ NO

If you prefer, you may refuse to answer this question, or you may discuss your answer in confidence with the senior minister rather than answering it on this form. Answering yes, or leaving the question unanswered, will not automatically disqualify an applicant for children or youth work.

Do you have a current driver's license? _______ YES ________ NO
CHURCH HISTORY AND PRIOR YOUTH WORK

Name of church of which you are a member:

List (name and address) other churches you have attended regularly during the past five years

List all previous church work involving youth (list each church's name and address, type of work performed and dates)

List all previous non-church work involving youth (list each organization's name and address, type of work performed and dates)

List any gifts, callings, training, education, or other factors that have prepared you for children or youth work:

Personal References (not former employers or relatives)

Name Name

Address Address

Telephone Telephone

APPLICANT'S STATEMENT

The information contained in this application is correct to the best of my knowledge. I authorize any references or churches listed in this application to give you any information (including opinions) that they may have regarding my character and fitness for children or youth work. In consideration of the receipt and evaluation of this application by Redeemer Evangelical Free Church, I hereby release any individual, church, youth organization, charity, employer, reference, or any other person or organization, including record custodians, both collectively and individually, from any and all liability for damages of whatever kind or nature which may at any time result to me, my heirs, or family, on account of compliance or any attempts to comply, with this authorization.

Should my application be accepted, I agree to be bound by the bylaws and policies of Redeemer Evangelical Free Church and to refrain from unscriptural conduct in the performance of my services on behalf of the church.

I further sate that I HAVE CAREFULLY READ THE FOREGOING RELEASE AND KNOW THE CONTENTS THEREOF AND I SIGN THIS RELEASE AS MY OWN FREE ACT. This is a legally binding agreement which I have read and understand.

Applicant's Signature Date

Witness Date
SCREENING REFERENCE FORM

Reference For Date

Position Applied For

Your name has been given to us as a reference for the above named individual. Kindly give us your estimate of the individual in terms of character, appearance, personality, personal data, etc. Our desire is to provide an atmosphere of excellence, warmth and safety that enables our children, youth and special needs adults to learn and experience the love of Christ as represented in our teaching staff. Your reply will be kept in strict confidence.

Please give your estimate of the individual's fitness in each of the items below:

1. Character _____Excellent _____Good _____Fair _____Poor _____Don't Know

2. Appearance
< Neatness and suitability of dress _____Excellent _____Good _____Fair _____Poor _____Don't Know

3. Personality
< Courtesy & consideration of others _____Excellent _____Good _____Fair _____Poor _____Don't Know
< Judgement and common sense _____Excellent _____Good _____Fair _____Poor _____Don't Know

4. Personal Data
< Warmth and love for children _____Excellent _____Good _____Fair _____Poor _____Don't Know
< Taking initiative _____Excellent _____Good _____Fair _____Poor _____Don't Know

5. How long have you known the applicant?

6. How well do you know the applicant? _____Casually _____ Fairly well _____Close relationship

7. Give your assessment of the applicant's Christian commitment

_____Strong personal commitment _____Growing, but needs support _____Somewhat inconsistent _____Nominally committed

8. Would you have this applicant working with and caring for your children?

If no, explain:

9. To what degree would you recommend this applicant?

_____Enthusiastically, without reservation _____Recommend _____Recommend, with some reservation _____Not recommend

10. Other comments:

Your Name

Phone Number Date

CHURCH ACTIVITY REQUISITION

Date

Name of person requesting activity

Telephone Number

Description of activity

Purpose of activity

Location of activity

Date(s) of activity
Type of transportation to activity

Cost per person for activity

CHURCH ACTIVITY PERMISSION FORM
(Name of Church)

Description of activity _____________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

Location of activity _______________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

Date(s) of activity _________________________________________________________________________

Type of transportation to activity _____________________________________________________________

________________________________________________________________________________________

Cost (if any) for activity ____________________________________________________________________

I give permission for _______________________________to participate in the above described activity.
Name of child

_____________________________________________
Parent/Guardian

_____________________________________________
Address

_____________________________________________
City/State/Zip

_____________________________________________
Telephone
TRANSPORTATION APPROVAL

Date _______________________

I give permission to ___________________________________ to ride with __________________________

in his/her vehicle on _____________________________. In understand that my son/daughter may be alone

with the above driver for a period of time.

_____________________________________________
Parent/Guardian

_____________________________________________
Address

_____________________________________________
City/State/Zip

_____________________________________________
Telephone