Safe Church Policy and Procedure Pilgrim Church United Church of Christ Sherborn, Massachusetts Adopted by Parish Board December 20, 2005
SUMMARY Pilgrim Church affirms that our church should provide a safe, secure environment for all who worship and participate in fellowship and ministry. This document describes operating guidelines, outlines reporting procedure, and includes forms necessary for the implementation of Safe Church policy. A Safe Church Committee (two to four members of the congregation) shall generally oversee Safe Church procedure and monitor that those with delegated responsibilities complete their charge. This committee shall also be the point of contact for criminal record checks and for incident reports. Building Keys will be limited to those with valid reason to have one and must be returned when that reason has expired. Emergency Evacuation of the Church Building shall be planned and practiced annually. Youth Protection shall require that all who participate in youth activities complete emergency contact forms, medical releases, and behavior covenants as required. Adults working with youth shall be screened, including a CORI check; trained in Safe Church procedure; and directed to avoid potentially compromising situations by being alone with a child in a non-public setting. Adult Conduct provisions prohibit sexual exploitation, harassment and ministerial misconduct by both staff and laity. Reporting of any incident initiates a process that begins with the Safe Church Committee, which notifies appropriate parties and works as a liaison between church boards, outside agencies and UCC personnel to assist in any necessary investigation. Pilgrim Church Forms are included at the end of this document. 2
A INTRODUCTION A.1 Purpose Pilgrim Church is committed to being a community of responsible Christian fellowship. Our intent is that all who participate in our church life, including children, adults, and church workers, whether paid or volunteer, will be able to explore their relationship with God and each other as they seek to grow in faith in an environment that is safe, secure and nurturing. A.2 Scope The policies and procedures included in this document apply to all activities which take place within the building and on the property of Pilgrim Church, as well as programs, activities, or events scheduled as part of the ministry of this church which take place elsewhere. The policies and procedures apply to all members, friends, volunteers, or employees of the church. A.3 Safe Church Committee Parish Board shall appoint two to four congregation members (preferably male and female) with Criminal Offender Record Information (CORI) clearance, to develop, implement and guide policy and procedure regarding church safety issues. These issues include, but are not limited to physical and sexual harassment, and abuse. The Committee will: Coordinate and implement policy and procedure contained in this document Appoint one member as authorized Point of Contact for CORI checks. Maintain file of CORI reports in secure, confidential church file. Maintain file of Incident Report Forms in secure, confidential church file. Monitor the assignment and distribution of church building keys. Monitor Safe Church training for those working with youth. Make recommendations, as needed, for improvements to the policy and facility. A.4 Distribution A copy of this document shall be distributed and acknowledged in writing by all clergy, staff, elected officers, youth advisors/mentors, and those relevant committee chairpersons and leaders identified by the Moderator. Permanent copies of this document shall be on file with the Church Administrator, the Christian Education Director, and the Safe Church Committee. B BUILDING KEYS Any person who seeks possession of a key to Pilgrim Church must have a clearly stated reason for needing a key and, if necessary, be approved by Parish Board. B.1 Authorized Holders 3
Certain people are authorized by virtue of their position in the church to hold keys. These include clergy, staff, worship leaders, officers, committee chairpersons, youth group leaders, etc. Others must receive the approval of the Moderator to have a key. B.2 Administration Keys will be assigned to authorized holders by the Church Administrator. The Church Administrator shall obtain a Key Receipt Form (Form 1) from each holder as well as a Key Return Form when the key is returned. It will be the responsibility of the Church Administrator to monitor who is in possession of keys and request the return of keys from persons no longer authorized to hold them. B.3 Proper Use Keys are not to be loaned to unauthorized persons, duplicated, or kept beyond the time that they are needed. C EMERGENCY EVACUATION OF BUILDING Protection of life is the primary concern in any emergency evacuation of the church. Pilgrim Church s emergency evacuation plan has been developed with particular attention to caring for those most in need of assistance, children and less mobile adults; to avoiding dangerous, potentially lethal, bottlenecks; and to keeping people clear of emergency vehicles. Teachers will evacuate students; parents will be a hazard to themselves and others if they attempt to exit through classrooms. If the alarm should sound or the order to evacuate given, everyone should calmly and efficiently follow these procedures: C.1 Sanctuary Able-bodied people in the sanctuary should leave by the main door to the narthex, walk down the northern stairs, exit the front door of the building, and walk to the church parking lot on the other side of Route 27. People requiring assistance will be helped down the southern stairs by the deacons, exit the front door of the building, and proceed to the Route 27 parking lot. Do not use the elevator in an emergency. If no one requires assistance, able-bodied people may leave down the southern stairs as well. Worship leaders and the choir should leave by the main door to the narthex with all other worshippers. C.2 Fellowship Hall Exit front door of the building and proceed to the Route 27 parking lot. C.3 Nursery Exit the office door of the building. Nursery personnel will escort children across Route 27 to the parking lot where they may be released to their parents. 4
C.4 Church School Each teacher should take attendance sheet, line up class, and exit as follows: all classes on ground floor, exit building through door in large classroom (Room 5); all classes on second floor, walk down office stairs, and exit building through office door. All classes will gather on grass in front circle area. Teachers take attendance and immediately notify safety personnel if someone is missing. Students will be accompanied across Route 27 to the parking lot by teachers where they may be released to their parents. C.5 Evacuation Drill A Sunday morning all-church evacuation drill shall be held annually. D. YOUTH PROTECTION D.1 Nursery (infants through 36 months) Staffing: Nursery care shall be supervised by an adult and, when necessary, the assistance of two students, aged thirteen or older. Adults must pass a CORI check (Form 2) and students must produce two recommendations (Form 3). Illness: To minimize contagion parents are asked to keep a child at home if he/she has a communicable disease or has had a fever in the last 24 hours. Upsets: It is our policy to give children time to settle into the nursery. However, parents may request, or be offered, a silent pager to retrieve them from worship if a child is inconsolable. Diapering: Diapers are changed only when necessary, using these guidelines. Use changing table in nursery. Always keep one hand on the child. Wear latex gloves. Use parent-provided diaper, or those from church supply. Use lotion or cream only if requested by parent. Wash hands following. Dispose of diaper and baby wipe in designated receptacle; put in outside dumpster when leaving. Release: Children will only be released to their own parents. Parents must notify supervising adult if other arrangements have been made. D.2 Church School (Age 3 through Grade 7/8 classes) 5
Teacher qualifications: Members of Pilgrim Church and those who have been attending or are otherwise known to the church for six months are invited to teach in the church school providing they pass a CORI check (Form 2) and participate in teacher training. High school aged teachers are recommended to be at least five years older than their students. Observation: An observation window should be in at least one door of each classroom. If not, doors may remain ajar or classrooms may be randomly visited during class time by a Christian Education Director. Toileting: Children in Grade Two and older may use the bathroom unescorted if they return promptly. This privilege may be granted or rescinded at the teacher s discretion. Younger children should be escorted to the bathroom by an adult, or nursery assistant, who shall remain at the open bathroom door while the child completes her/his task. Discipline: Appropriate limits are necessary to the growth and development of individual students as well as the class as a whole. Loving positive reinforcement is the primary tool of discipline at Pilgrim Church. Students will be recognized for appropriate behavior and redirected when heading for trouble. If necessary, a disruptive child will be removed from the classroom and sent to the Christian Education Director s office for a chat about appropriate behavior. When the child is ready to cooperate he/she will ask the teacher s permission to return to class. A second visit to the CE office will necessitate a friendly chat with parents. A third visit might require a short break from attending church school. No one shall use corporal punishment or subject students to cruel or severe punishment, humiliation, or verbal abuse. Field trips: Walking trips to a nearby public location during class time requires the prior permission of the Christian Education Director. Field trips involving transportation must have the prior written permission of parents and must adhere to the guidelines for all offsite activities (Form 4). Good judgment: No teacher or aide working with our children shall place him/herself in a compromising situation by being alone with a child in a closed or non-observable area. Reporting of incidents: Teachers should make note (Form 5) of any unusual incident that could cause potential physical or emotional harm to a student. This information will be passed on to the Safe Church Committee and the relevant parents. D.3 Youth Fellowship (Grades Six through Twelve) Parental responsibilities: Parents must complete an Emergency Form (Form 6) for each child attending youth group activities. Parents are responsible for promptly transporting their own child(ren) to and from youth group or making carpool arrangements. 6
Participant responsibilities: Students must agree to observe the group s covenant of behavior (Form 7). Those who cannot do so will be asked to leave the activity. Parents are responsible for providing prompt transportation and any associated cost. Supervision: Primary supervision is by the staff leader of each youth group. Members of Pilgrim Church and those who have been attending or are otherwise known to the church for six months may be invited to serve as fellowship advisors providing they pass a CORI check (Form 2) and participate in training. Each youth group activity is recommended to have at least one adult for each 6-10 students, with at least two adults present at all times. (See further recommendations for overnight trips.) Adult leaders and advisors are expected to be exemplary models of good behavior in the spirit of Christian fellowship and fun. They are to refrain from the use of alcohol, smoking, vulgarity, illegal drugs, or other inappropriate behavior, especially potentially compromising situations of being alone with a young person in a non-public area. Off-site activities: All off-site activities must follow the policies of fellowship activities. In addition, a parent must sign a permission slip specific to any off-site youth fellowship activity (Form 4). Disclosure must be made of location, any costs, dates and times, and transportation arrangements. All drivers should be at least twenty-five years old and show proof, if requested, of holding a valid driver s license and adequate liability insurance coverage. Overnights: All overnight trips require the approval of the Christian Education Committee and must follow the policies of fellowship and off-site activities. In addition, each participant must provide a completed Medical Release Form (Form 8). Originals must be taken with the accompanying adult leader while copies remain on file with the Church Administrator. The recommended number of adult supervisors is one per 4-6 students, with at least two adults present at all times. It is preferred that at least one volunteer be a man and one be a woman if both boys and girls are participating in the activity. Confirmation: Each confirmand will select a mentor who is an adult member of Pilgrim Church, providing that member passes a CORI check and participates in training. Mentors are expected to attend monthly confirmation classes and a weekend confirmation class retreat following the policies for all fellowship activities. In addition, mentors plan other activities with their confirmands. These activities must have the knowledge and consent of the confirmand s parents and are encouraged to take place with other mentor/confirmand groups in public places. Human Sexuality from a Christian Perspective: All policies for fellowship activities apply to this class which Pilgrim Church offers to its eighth graders in cooperation with Dover Church. The sensitive nature of the course material necessitates additional requirements including a parent orientation, student orientation, specific written parental 7
consent, and a specific student covenant of behavior. All classes will be taught by a qualified male and female team (not related by marriage) who have passed CORI checks (Form 2) and participated in relevant training. D.4 Training Staff, teachers, advisors, mentors and others working or volunteering in leadership positions with the youth of Pilgrim Church shall receive instruction, coordinated by the Christian Education Director, regarding appropriate conduct under Safe Church policy as part of their training. E ADULT CONDUCT E.1 Prohibition of Sexual Exploitation and Harassment Pilgrim Church is strongly opposed to sexual exploitation and harassment of any kind, and such behavior is prohibited by church policy. Sexual harassment includes sexual advances, requests for sexual favors or verbal, emotional or physical conduct of a sexual nature, which has the purpose, or effect, or creating an intimidating, humiliating or sexually offensive environment. It is the intention of Pilgrim Church to respond to allegations of behavior that are contrary to this policy and, if necessary, to discipline those persons who violate it. E.2 Policy of Ministerial Conduct All people engaged in the ministry of Pilgrim Church (including elected or appointed leaders, staff, volunteers and authorized ministers) are responsible for knowing the possible impact of their words and actions in ministering to the emotional, mental and spiritual need of those who come to them for help or over whom they have any kind of authority. Sexual exploitation of parishioner(s) or other individual(s) by anyone engaged in the ministry of Pilgrim Church is unethical and unprofessional behavior and will not be tolerated. F REPORTING F.1 Role of Safe Church Committee It is not the Committee s role to decide whether an incident took place, but to notify the responsible parties to do so, including but not limited to the church attorney, insurance agency, department of social services and local law enforcement. The Committee works as a liaison between boards, committees, outside agencies and UCC personnel to assist in any necessary investigation involving church members, volunteers, friends of the church or employees. F.2 Procedures for Reporting Allegations of Physical or Sexual Misconduct or Harassment a. Any allegation shall be reported immediately to the Safe Church Committee. 8
b. The Committee member receiving the allegation shall complete an Incident Report Form (Form 5), taking the information from the informant, within 48 hours, and inform other Committee members. c. The following people should be contacted immediately: Church Senior Minister Church Attorney Church Insurance Agency Local Law Enforcement (if agreed between committee and attorney) followed by written confirmation of the contact. d. Clergy and the Christian Education Director are mandated reporters to the Department of Social Services and therefore it will be their job to report such allegations as required by law. e. Should the incident involve an employee of the church, the Personnel Chairperson should be contacted as soon as possible and the Personnel Guidelines should be followed regarding the handling of the allegation. f. Should the incident involve an allegation against the Pastor; the Personnel Chairperson, Senior Deacons, Moderator, Chairperson of Pastoral Relations and the UCC Association Committee on the Ministry shall be contacted as soon as possible and the procedure in Guidelines for Resource Committees on the Ministry shall be followed. g. Should the incident involve an allegation against a church member, volunteer or friend of the church, the following procedure will be followed: A full Safe Church Committee meeting shall be held no later than 7 days after the report of the allegation. The Committee shall make a formal recommendation of how to proceed with the allegation, based on the facts of the allegation and any direction given by the church attorney, insurance agency, and department of social services and/or local law enforcement. The Committee will proceed in the following recommended manner: The member, volunteer or friend of the church shall be notified that an allegation has been made. The member, volunteer, or friend of the church shall be removed from any position held within the church until the allegation is resolved, however any member, volunteer or friend of the church shall be welcome to worship with the general congregation and to receive pastoral care as arranged by the church. 9
If a minor is involved, the child s parents and/or guardians shall be notified of the allegation. No formal investigation shall take place by the Committee unless recommended and guided by the church attorney and insurance agency. Any and all conversations, meetings, or discussions regarding the allegation shall be recorded in writing and kept in the secure, confidential Safe Church file. The utmost respect shall be given to the confidentiality and privacy of all parties. Should an investigation find a member, volunteer or friend of the church guilty of the allegation, the Committee shall meet to determine further action to take regarding that person. Each determination shall be made on a case-by-case basis and shall take into consideration all facts and or charges involved. 10
G Pilgrim Church Forms (appended) Forms for Commonwealth of Massachusetts Criminal History Systems Board (available at www.mass.gov/chsb) 11
PILGRIM CHURCH UCC FORM 1/12.08.05 Key Receipt YOUR NAME (print clearly): DATE: Please choose one of the following: I am a Pilgrim Church member and am receiving Key # for the following purpose:. I am not a Pilgrim Church member and am receiving Key # for the following purpose:. Please initial each of the following paragraphs to indicate you understand and will comply with the conditions set forth by Pilgrim Church for holding a key: I acknowledge receipt of a key to Pilgrim Church and agree that: I will not lend this key to anyone else. I will not duplicate this key. I will not tag or otherwise identify this key as providing access to Pilgrim Church. I will be entirely responsible for the security of this key. I will return this key when I no longer have the responsibility for the above named purpose or when the Property Trustees request its return. YOUR INITIALS: I understand that, as a key holder, I am responsible for the Safe Church Policies and Procedures that the key I hold unlocks while at Pilgrim Church. I will not be alone in any room of Pilgrim Church with a child or youth other my own at any time. YOUR INITIALS: I understand that failure to comply with any of the provisions set forth in this document may result in my loss of privilege to be a key holder. YOUR INITIALS: MY SIGNATURE: TELEPHONE: PILGRIM CHURCH ADMINISTRATOR: $10 deposit received (non-member) CHECK # EXPECTED DATE OF KEY RETURN: Key Return I have returned Key # to the Church Administrator of Pilgrim Church. MY SIGNATURE: DATE: PILGRIM CHURCH ADMINISTRATOR: 12
PILGRIM CHURCH UCC FORM 2/12.08.05 Authorization for CORI Check Pilgrim Church is committed to creating a safe and healthy environment in which young people can learn about and experience God s love. In order to ensure this, we expect all applicants for staff and authorized volunteer positions who will work with minors to undergo a CORI check of prior convictions and pending criminal cases. As an applicant for the staff/authorized volunteer position of, I understand that a criminal record check will be conducted for conviction and pending criminal case information only and that it will not necessarily disqualify me. The information below is correct to the best of my knowledge. APPLICANT SIGNATURE --------------------------------------------------------------------------------------------------------------------- (Please print) LAST NAME FIRST NAME MIDDLE NAME MAIDEN NAME OR ALIAS, IF APPLICABLE DATE OF BIRTH SOCIAL SECURITY NUMBER MA DRIVER S LICENSE NUMBER PHOTO ID PROVIDED ADDRESS Requested by: SIGNATURE OF CORI AUTHORIZED AGENT --------------------------------------------------------------------------------------------------------------------- Criminal History Systems Board Use Only Record attached: No record: 13
PILGRIM CHURCH UCC FORM 3/12.08.05 Student Assistant in Nursery Application The Pilgrim Church Nursery serves children from six weeks to three years of age. An adult director and two student assistants (who must be Grade 9 or older) staff the Nursery. Student assistants fill an important role and should take their responsibilities seriously. They are expected to: Work cooperatively under the director s supervision. Stay alert to the children s needs. Actively engage the children in appropriate activities. Be reliable and punctual. Find own substitutes when necessary. Student assistants work from 9:45-11:45 a.m. on Sunday mornings during the program year, September through June. Schedule assignments are flexible and determined cooperatively by the director and student assistants. YOUR NAME GRADE ADDRESS TELEPHONE WHAT IS YOUR CHILDCARE EXPERIENCE? DO YOU HAVE ANY OTHER WORK EXPERIENCE? REFERENCE FROM YOUR CHILDCARE EXPERIENCE: NAME TELEPHONE ADDRESS REFERENCE FROM A MEMBER OF PILGRIM CHURCH: NAME TELEPHONE ADDRESS I affirm that Pilgrim Church should provide a safe and secure environment for children who participate in our programs. Should my application be accepted, I agree to be bound by the policies of Pilgrim Church and to refrain from inappropriate or irresponsible conduct toward children in the performance of my work for the church. SIGNATURE OF APPLICANT RETURN TO: Christian Education, Pilgrim Church UCC, 25 South Main Street, Sherborn, MA 01770 14
PILGRIM CHURCH UCC FORM 4/12.08.05 Off-Site Activity Permission Slip ACTIVITY & LOCATION: DATE & TIME: EXPECTED COST: LEADER & ADVISORS: METHOD OF TRANSPORTATION: ------------------------------------------------------------------------------------------------------------------------------ PLEASE FILL OUT AND RETURN BOTTOM PORTION OF THIS FORM I give my son/daughter permission to participate in the above activity with Pilgrim Church UCC youth. CHILD S NAME: TELEPHONE: PARENT/GUARDIAN SIGNATURE: DATE: Telephone number where I may be reached during activity, if necessary: Yes, I am over 25 years old, hold a valid Massachusetts driver s license, carry sufficient auto liability insurance, and would be able to drive people in addition to myself in my car (with current inspection sticker) to this activity. 15
PILGRIM CHURCH UCC FORM 5/12.08.05 Incident Report This form is to be used to register all injuries/mishaps that take place during church programs or events that take place on or off church premises. It is also to be used for all suspicions of child abuse or neglect. Names and telephone numbers of those involved in the incident: Date and location of incident: Name and telephone number of person observing or receiving disclosure of incident: Briefly describe the nature and extent of the injury, accident, or abuse (clarify whether observed first hand or reported by other party): Action taken by on-site leader Report filed by Date: Reported to Christian Education Director or Youth Leader. DATE: Reported to parent or guardian. DATE: Reported to Safe Church Committee. DATE: 16
PILGRIM CHURCH UCC FORM 6/12.08.05 Youth Group Emergency Form Name of student: Date of birth: Student s address: Telephone: Parent s name: Day telephone: Address (if different): Other phone: Place of employment: Parent s name: Day telephone: Address (if different): Other phone: Place of employment: If parents are separated/divorced, who has legal custody? Released to other parent? ` Step parent, guardian, au pair or other significant adult in student s home? Physician: Telephone: Dentist: Telephone: Preferred hospital: Telephone: Medical insurance company: ID# Name and telephone number of persons authorized to assume responsibility in an emergency if parent are not available (must list three local persons): Name: Relationship: Telephone: Name: Relationship: Telephone: Name: Relationship: Telephone: Does the student have any significant health problems or allergies? Please explain, using reverse side if necessary. If none, indicate by writing none. List any medication(s) that your child takes on a continuing or regular basis, including dosage and frequency. If none, indicate by writing none. In the event of an emergency, I hereby give permission to any Pilgrim Church staff member or authorized leader to administer first aid as may be necessary during any time when neither I nor any other person listed above can be reached; and to transport my child to the nearest emergency care facility; and for the staff of that facility to administer and to perform such emergency procedures as needed to aid my child. Parent signature Date: 17
PILGRIM CHURCH UCC FORM 7/12.08.05 Middle School Youth Group Covenant Our church-based program brings sixth and seventh graders together in a Christian fellowship community to share fun with their peers, to develop an awareness of their spirituality, and to serve others through various outreach projects. To help you grow as a responsible and considerate participant, everyone in the community must share in a promise, or covenant, that its members make to each other. Please read the covenant carefully and talk with your family about what it means to you. The success of the community will depend on the effort each and every member makes to live up to the promise. I, promise that I will: BRING MY BEST BEHAVIOR TO FELLOWSHIP. I will treat everyone, including myself, with respect. I will offer my good will, interest, cooperation and friendship to all. I will recognize the good qualities of all the members of the community and appreciate them. And, I will be a responsible caretaker of my surroundings. BE A REAL MEMBER OF THE FELLOWSHIP COMMUNITY. I will participate as faithfully and often as I am able. I will take part in all aspects of the program spiritual and service as well as social. I will take responsibility for reservations and deadlines and I will honor my commitments. WELCOME THE PARTICIPATION OF MY FAMILY. I will recognize my family as an invaluable part of my fellowship community by keeping them informed about my activities and seeking their assistance as volunteers. CONTRIBUTE RESOURCES TO FELLOWSHIP. I will bring what gifts I have be they talent, time or treasure and share them generously with others. Student signature: Date: Address: Parent signature: Telephone: 18
PILGRIM CHURCH UCC FORM 8/12.08.05 Overnight Medical Release Form (Name of youth) has my permission to attend the at from to. (Signature of Parent or Guardian) (Date) Medical and Insurance Information and Permission for Treatment (Parent or guardian) does hereby authorize and empower the Pilgrim Church Youth Group Leader and other adult advisors to take such actions as, in his/her opinion, shall be necessary for the welfare of his/her minor child including without limitations, medical and/or surgical treatment. NAME (parent or guardian) ADDRESS PHONE (home) (business) INSURANCE COMPANY Address Phone Policy # If group insurance, name Subscriber Student Birth Date Youth s Physician City Phone In the event of an emergency (when parent/guardian cannot be reached), please notify: Name Relationship Phone Name Relationship Phone Please complete the following medical information Current medical treatment Medication(s) Dosage Self-Administered? Date of last tetanus shot (month/year): Allergies? (specify) (over) 19
Consent to Administer Medical Treatment I/We, the undersigned, parent(s)/legal guardian(s) of, do hereby consent to any x-ray exam, anesthetic, medical or surgical diagnosis or treatment, and hospital service that may be rendered to said minor, under the general, specific instructions of (name of student s physician) or, if unavailable, two on-call physicians at an accredited health care facility. It is understood that this consent is given in advance of any specific diagnosis or surgical or medical treatment. This consent shall remain in effect until the day of,, delivered to said persons entrusted with the care, custody and control of said minor child. I understand that any and all medical expenses incurred during this emergency are my responsibility and there is not medical coverage provided by Pilgrim Church. Parent or Guardian s signature Date During the time period of, I can be reached by telephone at: Home Work Other 20
PILGRIM CHURCH UCC FORM 9/05.12.06 Summer Activity Leader Application Pilgrim Church provides supervised activities for children ages 3-7 during worship services throughout the summer schedule. The Leader must be age 18 or older and have child care experience. In addition, all applicants must successfully complete a CORI check. Pilgrim Church is committed to creating a safe environment for everyone participating in its ministries. The Summer Activity Leader is expected to: Plan and actively engage the children in appropriate activities. Be reliable and punctual. Find own substitutes when necessary. Leave areas used clean and tidy. Report any difficulties to head usher. The Leader works from 8:45-10:15am on summer Sundays, June 18-September 3 in 2006. YOUR NAME DATE OF BIRTH ADDRESS TELEPHONE WHAT IS YOUR CHILDCARE EXPERIENCE? DO YOU HAVE ANY OTHER WORK EXPERIENCE? REFERENCE FROM YOUR CHILDCARE EXPERIENCE: NAME TELEPHONE ADDRESS REFERENCE FROM A MEMBER OF PILGRIM CHURCH: NAME TELEPHONE ADDRESS I affirm that Pilgrim Church should provide a safe and secure environment for children who participate in its ministries. Should my application be accepted, I agree to be bound by the policies of Pilgrim Church and to refrain from inappropriate or irresponsible conduct toward children in the performance of my work for the church. I also affirm there is no fact or circumstance involving me or my background that would call into question my being entrusted with the responsibilities of the position for which I am applying. SIGNATURE OF APPLICANT RETURN TO: Christian Education, Pilgrim Church UCC, 25 South Main Street, Sherborn, MA 01770 21