Upper Columbia Conference VOLUNTEER Service Information Form and Screening Packet CHURCH CHURCH SCHOOL SABBATH SCHOOL PATHFINDER CLUB STAFF ADVENTURER CLUB STAFF PARENT VOLUNTEERS ALL VOLUNTEERS ALL DRIVERS FOR CHURCH AND SCHOOL SPONSORED OUTINGS (DAY AND/OR OVERNIGHT TRIPS) In order to protect our children and youth, the North American Division of Seventh-day Adventists, the Upper Columbia Conference of Seventh-day Adventists, and insurance policies require all churches, schools, and clubs to screen backgrounds on every volunteer and worker who works directly and indirectly with children and youth under the age of 18. Our greatest desire is to assist each church, school, club in doing what is prudent, legal and necessary in order to protect them. Enclosed are the background screening forms. Thank you for taking the time to complete these forms. Your diligence helps to ensure a safe environment for all children and youth who attend a Seventh-day Adventist church, school, or club. This packet contains: Volunteer Service Information Form Complete all sections of each form Guidelines for Volunteers & Caregivers Include complete addresses, zip codes & area codes Sign and date each form Please make sure you: Return immediately completed packet to: UCC Volunteer Services Upper Columbia Conference of Seventh-day Adventists 3715 South Grove Road Spokane, WA 99224 509-838-2761 10/2011 Update OFFICE USE ONLY Date Received References Sent: Received: Date recommended with conditions noted: Date recommend: Date not recommended: Note conditions: Signature of Upper Columbia Conference personnel completing screening process: Volunteer Service Information Form (VSIF) Other: Section II -DRIVER INFORMATION Current Driver’s License # ______________________________ State _________ Expiration Date ______________ Other State driver’s license within the last 2 years. State __________________ License # ______________________ Name of Insurance Carrier: _________________________ Insurance # ________________Expiration Date ________ List all traffic violations and at-fault accidents in the last two years: __________________________________________ ________________________________________________________________________________________________ Section III -HEALTH INFORMATION List any injury/disability/health factor that might limit your involvement as a volunteer with children/youth or impact the health of children (i.e. communicable diseases, physical limitations). Check area you will work with children. Write in name of school, church, club. School Name ____________________ Church Name ___________________ Church Leader Position:_____________________ Sabbath School Pathfinder Club _________________ Adventurer Club ________________ Camp Meeting Youth Department Vacation Bible School Department__________________ SECTION I -PERSONAL INFORMATION Please print legibly, completing ALL sections below. Name (Last, First, M.I.) Male Female Address State Zip City Home Phone ( ) Day Phone ( ) Date of Birth Email: How long have you lived at this address? In this state? List all other states lived in the last 7 years: Marital Status: Married Single Divorced Separated Children living at home? Yes No Grown children? Yes No Are you an SDA church member? Yes No How long: Church(s) attended the last 5 years? I authorize Upper Columbia Conference of SDA to conduct a criminal history search Yes No Have you ever been (formally or informally) accused, charged, convicted, or disciplined for any unlawful sexual conduct, abuse, child neglect, child abuse, and/or child sexual abuse? Yes No Have you ever been denied legal custody of your children for any reason? Yes No Have you ever been registered as a sex offender in any jurisdiction? Yes No Date: Place: If you answered yes, please supply the date, place, type of conduct, disposition and sentence: Please check the box(s) that applies Section IV -UNLAWFUL CONDUCT Section VI -REFERENCES Section V -LANGUAGES SPOKEN Please list all languages (including English) that you speak, read and write proficiently language speak 1. English 2. __________ 3. __________ read write Comments List below individuals who could recommend you for service with children and/or youth. DO NOT LIST RELATIVES Name Street City State Zip Phone/Email address 1. Pastor 2. A teacher who knows you 3. Other Section VI -STATEMENT OF ACCURACY As applicant the information contained in this application is correct to the best of my knowledge. I authorize any references, churches and/or schools listed in this application to give any information that they may have regarding my character and fitness for working with children or youth. I hereby release any individual, church, school, or organization from any and all liability for damages that may result to me, my heirs, or family for compliance with this authorization. I also authorize the Upper Columbia Conference of Seventh-day Adventists to seek investigative background inquiries including criminal convictions, motor vehicle, and other reports. Your signature on this form confirms your understanding and agreement that in the event allegations of criminal or sexual misconduct arise regarding your conduct while you serve in the above-described capacity(ies), the conference will fully cooperate with any investigation. I further state that I have carefully read the foregoing release, and understand 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. This form will become a permanent record. In the event of accusations against the applicant, opportunity should be given for response by the accused. The response also becomes a part of the record. Applicant’s signature: ___________________________________________________ Date: ___________________ GUIDELINES FOR VOLUNTEERS & CAREGIVERS Because our society is filled with pain, problems and litigation caused by improper conduct of adults working with children and youth, it is imperative that those working with children at church and schools have meaningful guidelines for conduct -to protect both themselves and those under their care. As a ministry volunteer, you want parents and others to feel comfortable and confident with you. Here are some practical guidelines: 1. Never leave unattended a child or group of children for whom you are responsible. Provide adequate supervision at all times, no matter what. 2. NEVER be the only adult serving as a caregiver – ALWAYS have at least one other person 18 years of age or older with you. 3. Always ask a person’s permission before touching him/her anywhere, even when responding to an injury or problem. This is especially true for any area that would normally be covered by a T-shirt and shorts. If an injury is within this area, make sure another adult works with you as you provide care. 4. Physical and verbal attacks are inappropriate and should not ever be used as discipline. “Time out” or “sit-in-that-chair” may be helpful methods with children. 5. Kids need to be touched appropriately. However, keep hugs brief and “shoulder-to-shoulder” or side-to-side.” Always keep your hands at (not below) the shoulder level. For small children who like to sit on laps, encourage them to sit next to you. 6. When taking small children to the bathroom take another adult along or leave the door open. 7. Be aware of the signs and symptoms of abuse. Be aware of the legal requirements in your locality for reporting child abuse. In nearly all places, a caregiver can be held legally responsible for failing to report suspected or actual child abuse. 8. Be loving, kind, firm, and always thoroughly professional as a caregiver. Working with children and youth is not only a privilege; it is also a responsibility that must be approached with utmost care. 9. Be aware of conducting activities in rooms that do not have an interior viewing area, or I will leave the door open during the activity to allow easy observation by others.. Upper Columbia Conference Driving Policy for all persons transporting children or youth for church and school related activities whether the vehicle is church-owned or privately owned: “Drivers shall have an acceptable driving record during the previous three years with not more than two traffic citations and no at-fault accidents while driving any vehicle. When a driver does not meet the above driving standard, he/she shall not be assigned to or retained for a driving position.” -NAD Policy Manual, p. 50. I, the undersigned caregiver, have read the guidelines listed above and agree to abide by them. I will obtain a copy of this signed form and keep it for reference. SIX MONTH RULE: If you have just moved to the area, or recently changed your membership to your current church, you will not be approved as a volunteer until six months have passed. This allows the church/school/club time to get to know you. DATE_____________________ SIGNED________________________________________________