2025/2026 ANNUAL UPDATE Children/Youth Volunteer

This agreement is to be completed each year by all workers/helpers for any position (volunteer or compensated) involving the supervision or custody of minors. This is to be handed into the church office. All agreements will be kept confidential, will only be read by pastoral staff/ministry leader(s), and will be stored in a secure location at the church office. Additional forms and resources mentioned on this form can be found on our church website, ffbic.org: Ministries/Children/Keeping Our Children Safe.

Your name *

Email address *

Address *

Phone number *

Birthdate *

Background Information

I have been a resident of the state of Pennsylvania for the past 10 years (continuously). *

Have you ever participated in, or been accused, charged or convicted of child abuse (physical or emotional), child neglect, or a crime involving actual or attempted sexual molestation of a minor? *

Please type your answer: Yes OR No. If your response is "Yes," please explain further.

Have you ever been charged with, convicted of or pleaded guilty to a crime in which you harmed another person physically, sexually, emotionally, or financially? *

Please type your answer: Yes OR No. If your response is "Yes," please explain further.

Have you ever physically, sexually, or verbally abused an infant, child or youth? *

Please type your answer: Yes OR No. If your response is "Yes," please explain further.

Have you ever been charged with, convicted of or pleaded guilty to any criminal offense of any kind? *

Please type your answer: Yes OR No. If your response is "Yes," please explain further.

Are you aware of any traits or tendencies you possess that could pose any threat to children or youth? *

Please type your answer: Yes OR No. If your response is "Yes," please explain further.

I have read the Five Forks Brethren in Christ Church Child Abuse Prevention (CAP) Policy Book. *

Our current policy can be accessed from our church website, ffbic.org: Ministries/Children/Keeping Our Children Safe.

I agree to comply with the Five Forks Brethren in Christ Church’s CAP policies. *

Please list your current driver’s license number and state that it was issued. *

Have you been convicted of a traffic offense in the past 5 years? *

Please type your answer: Yes OR No. If your response is "Yes," please explain further.

Worker's Statement

The information contained in this agreement is correct to the best of my knowledge. I authorize any references or churches listed in this agreement to give Five Forks Brethren in Christ Church 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 agreement by Five Forks Brethren in Christ Church, I hereby release any individual, church, youth organization, charity employer, 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, provided they do so in good faith and without malice and that I have the right to inspect such references provided on my behalf. I waive any right that I may have to remove or change any information provided about me by any person or organization identified by me in this application.

I testify I have read the Five Forks Brethren in Christ Church Child Abuse Prevention Policies. I agree to be bound by the CAP Bylaws and policies of Five Forks Brethren in Christ Church and to refrain from unscriptural conduct in the performance of my services on behalf of the church. I further declare that with regard to my personal, moral, and ethical character and conduct as of this date, I am not engaged in inappropriate conduct toward minors, nor do I have inclinations toward such conduct. I also certify that I understand the provisions of the Child Abuse and Neglect Reporting Laws in Pennsylvania, where the Five Forks Brethren in Christ Church is located, and that I will comply with the provisions of the reporting laws of Pennsylvania (If you think a child has been abused: Stay calm; Give emotional support; Believe the child; Get medical help; Speak with the Pastor/Director of Children or Student Ministries and either you or the Pastor/Director will Contact ChildLine at (1-800-932-0313). A complete “Recognizing & Reporting Child Abuse” guide, put out by the Commonwealth of PA, is in the church office.

I further state that I have carefully read this document 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.

Signature: (DISCLAIMER: By typing your name below, you are signing this form electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this form.) *

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