Child Safety Governing Policy

“Jesus called the children to him and said,
‘Let the little children come to me, and do not hinder them, for the Kingdom of God belongs to such as these.’” 
Luke 18:16

Peace Lutheran Church
P.O. Box 655
2355 Clark Road
Dresser, Wisconsin 54009

Phone: 715-755-2515
FAX: 715-755-2525
E-mail: peace@centurytel.net

Adopted by the congregation on January 30, 2005

INDEX

POLICY

Child Safety Governing Policy ............................................................. Pages 1-2

PROCEDURES

Policy # 1: New Member Orientation ........................................................ Page 3
Policy # 2: Employee Screening ............................................................... Page 4
Policy # 3: Volunteer Screening ................................................................ Page 5
Policy # 4: Reference Requirements ......................................................... Page 6
Policy # 5: Criminal Records Check .......................................................... Page 7
Policy # 6: Applicant With Criminal Sexual Abuse Record ....................... Page 8
Policy # 7: Two Adult Rule ........................................................................ Page 9
Policy # 8: Review And Training .............................................................. Page 10
Policy # 9: Windows On Doors ................................................................ Page 11
Policy # 10: Visiting Organization Use Of The Church Facility ................ Page 12
Policy # 11: Reporting An Incident ........................................................... Page 13
Policy # 12: Government Reporting Procedures ...................................... Page 14
Policy # 13: Responding To A Suspected Incident .................................. Page 15

FORMS

Form A - Employment Application Form ............................................ Page 17-18
Form B - Reference Contact Form .......................................................... Page 19
Form C - Background Investigation Consent Form ................................. Page 20
Form D - Volunteer Application Form ...................................................... Page 21
Form E - Notification Of Ineligibility Form ............................................... Page 22
Form F - Visiting Organization Form ....................................................... Page 23
Form G - Report Of Suspected Incident Of Child Sexual Abuse Form ... Page 24

TRAINING MATERIALS

What Is Child Sexual Abuse? .................................................................. Page 25
What Does An Abuser Look Like? ........................................................... Page 26
Symptoms Of Abuse ................................................................................. Page 26
What Peace Lutheran Church Is Doing .................................................... Page 26
What You Can Do .................................................................................... Page 27

CHILD SAFETY GOVERNING POLICY

Background

Child sexual abuse is a serious concern in our society and in many churches. Acknowledging the broken and sinful nature of our world, we accept it as our responsibility to provide as safe an environment as we can for our children and everyone who works with them.

Therefore, Peace Lutheran Church has established the following Statements of Purpose, Covenant, and Policies which, when taken together, constitute the congregation’s Child Safety Governing Policy.  An additional booklet is available from the Church Office which specifies the procedures, forms, and training materials used to implement the Child Safety Governing Policy at Peace Lutheran Church.

Statement of Purpose

Peace Lutheran Church’s purpose for establishing a Child Safety Governing Policy is to demonstrate our absolute and unwavering commitment to the physical and emotional safety and spiritual growth of our children and those who work with them.

Statement of Covenant

As a Christian community of faith and a member of the Evangelical Lutheran Church in America, we, the members of Peace Lutheran Church, pledge to conduct the ministry of our congregation in ways that assure the safety and spiritual growth of our children and those who work with them.

Toward that end, we commit ourselves to:
•	Follow established procedures in the selection and recruitment of employees and volunteers who work with children;
•	Implement procedures which minimize the risk of sexual abuse to children;
•	Educate our employees and volunteers who work with children about our Child Safety Governing Policy and the procedures associated with it;
•	Make it known in the congregation that all the members of Peace Lutheran Church are an essential part of providing a safe environment for our children;
•	Make copies of our Child Safety Governing Policy readily available;
•	Follow clearly defined procedures for reporting a suspected incident of child sexual abuse that conforms to the requirements of the law; and
•	Be prepared to respond to inquiries from the general public, the media, and/or members of the congregation if an incident of child sexual abuse occurs.

Statement of Policies

1.	Peace Lutheran Church will provide to all new members, as part of the New Member Orientation Meeting, a copy of the Child Safety Governing Policy.

2.	Peace Lutheran Church will employ a screening program for all employees who work with children and are likely to be in potentially high risk situations with them.  Examples of this would include employees who participate in mission trips and overnight events with children.

3.	Peace Lutheran Church will employ a screening program for all volunteers who work with children and are likely to be in potentially high risk situations with them. Examples of this would include volunteers who participate in mission trips and overnight events with children.

4.	Peace Lutheran Church requires that all screened employees and all screened 	volunteers have at least three references checked.

5.	Peace Lutheran Church requires that all screened employees and all screened 	volunteers sign a release for a criminal background check.

6.	It is Peace Lutheran Church’s policy that no one with a known record who has been convicted of a sexual abuse crime of any kind will be allowed to work with children.

7.	To ensure a safe environment for our children and to protect those who work with them from false accusations, Peace Lutheran Church will use a “two adult rule” for designated activities with children.

8.	To ensure that the Child Safety Governing Policy has been effectively implemented, members of the Parish Relations Ministry will periodically review the policy and conduct training events for the employees of the congregation and the volunteers who work with children.

9.	To provide added safety, all rooms in our church’s building, except bathrooms and storage closets, will have windows in their doors.

10.	Peace Lutheran Church encourages the use of its facility by visiting organizations and opens its doors to organizations which need space for events involving children. To ensure the safety of all children, Peace Lutheran Church requires that visiting leaders abide by the Child Safety Governing Policy.

11.	Child sexual abuse is criminal behavior that involves children in sexual behaviors as defined by state and federal law.  All employees and volunteers who work with children at Peace Lutheran Church are required to immediately report any concerns related to suspected incidents of child sexual abuse to the Parish Relations Ministry Chairperson, the President of the Church Council, or the Senior Pastor. 

12.	In responding to a suspected incident of child sexual abuse, Peace Lutheran Church will work with appropriate government agencies in a prudent manner to ensure the safety and dignity of the suspected victim and the person who has been accused.

13.	Following the report of a suspected incident of child sexual abuse, Peace Lutheran Church will follow established procedures when responding to inquiries made by the general public, the media, and/or members of the congregation. First and foremost, these 	procedures will protect the rights of the suspected victim, as well as the rights of the person who has been accused.

Adopted by the congregation of Peace Lutheran Church on January 30, 2005

POLICY # 1: NEW MEMBER ORIENTATION

Peace Lutheran Church will provide to all new members, as part of the New Member Orientation Meeting, a copy of the Child Safety Governing Policy.

Those Responsible for Implementation

Parish Relations Ministry (primary)
Life and Growth Ministry

Procedures for Implementation

1.	The Child Safety Governing Policy will be included as a part of the New Member 		Orientation materials given to all those who join Peace Lutheran Church.

2.	During the New Member Orientation meeting, key points of the policy will be 			highlighted verbally by a member of the Parish Relations Ministry or designee thereof.

Associated Documents and/or Forms

Child Safety Governing Policy

POLICY # 2: EMPLOYEE SCREENING

Peace Lutheran Church will employ a screening program for all employees who 	work with children and are likely to be in potentially high risk situations with them.  Examples of this would include employees who participate in mission trips and overnight events with children.

Those Responsible for Implementation

Parish Relations Ministry (primary)
Life and Growth Ministry

Procedures for Implementation

Application: 	To be used with all full-time and part-time employees, including clergy, who are 			likely to be in potentially high risk situations with children.

1.	All applicants will complete and submit to the Parish Relations Ministry the Employment 	Application Form (Form A).

2.	A member of the Parish Relations Ministry will serve as a member of the Interview 		Committee and will take detailed notes of the interview.

3.	The Parish Relations Ministry member of the Interview Committee will contact the 		references listed on the Employment Application Form (Form A) and complete the 		Reference Contact Form (Form B).  (See Policy # 4.)

4.	All applicants will complete the Background Investigation Consent Form (Form C).  		Criminal record checks will be conducted by the Parish Relations Ministry member of 		the Interview Committee or designee thereof.  (See Policy # 5.)

5.	All forms, notes, and documents associated with the applicant will be collected together 	as part of the applicant’s personnel record and filed for future reference by the Church 		Secretary.  Form C - Background Investigation Consent Form will be considered 		confidential and will be kept in a locked file in the church office.  Only the Parish 		Relations Ministry Chairperson, the Church Secretary, and the Senior Pastor will have 		access to the personnel files.

6.	Appropriate action will be taken by the Parish Relations Ministry based on the 			information presented.

Associated Documents and/or Forms

Form A - Employment Application Form 
Form B - Reference Contact Form
Form C - Background Investigation Consent Form

POLICY # 3: VOLUNTEER SCREENING

Peace Lutheran Church will employ a screening program for all volunteers who work with children and are likely to be in potentially high risk situations with them. Examples of this would include volunteers who participate in mission trips and overnight events with children.

Those Responsible for Implementation

Parish Relations Ministry (primary)
Life and Growth Ministry
Youth Ministry
Education Ministry

Procedures for Implementation

Application: 	To be used with all volunteers who are likely to be in potentially high risk 				situations with children.

1.	All applicants will complete and submit to the Parish Relations Ministry the Volunteer 		Application Form (Form D).

2.	A member of the Parish Relations Ministry, or designee thereof, will interview the 		volunteer applicant and will take detailed notes of the interview.

3.	The Parish Relations Ministry member, or designee thereof, will contact the references 		listed on the Volunteer Application Form (Form D) and complete the Reference Contact 	Form (Form B).  (See Policy # 4.)

4.	All applicants will complete the Background Investigation Consent Form (Form C).  		Criminal record checks will be conducted by the Parish Relations Ministry member, or 		designee thereof. (See Policy # 5.)

5.	All forms, notes, and documents associated with the applicant will be collected together 	as part of the applicant’s personnel record and filed for future reference by the Church 		Secretary.  Form C - Background Investigation Consent Form will be considered 		confidential and will be kept in a locked file in the church office.  Only the Parish 		Relations Ministry Chairperson, the Church Secretary, and the Senior Pastor will have 		access to the personnel files.

6.	Appropriate action will be taken by the Parish Relations Ministry based on the 			information presented.

Associated Documents and/or Forms

Form B - Reference Contact Form
Form C - Background Investigation Consent Form
Form D - Volunteer Application Form

POLICY # 4: REFERENCE REQUIREMENTS

Peace Lutheran Church requires that all screened employees and all screened volunteers have at least three references checked.

Those Responsible for Implementation

Parish Relations Ministry

Procedures for Implementation

1.	As part of the application form (Form A or D), all applicants will provide a minimum of 		three (3) names to be used as references.  These references are to be unrelated to the 	applicant either by blood or marriage.

2.	A member of the Parish Relations Ministry, or designee thereof, will contact all three 		submitted references 	using the Reference Contact Form (Form B) to record all notes.

3.	If a listed reference refuses to release any information to Peace Lutheran Church, this 		will be noted on the Reference Contact Form (Form B).

4.	If a listed reference cannot be reached, this will be noted and a new reference will be 		provided by the applicant.

5.	All information obtained from the reference contacts will be considered confidential.  		The completed Reference Contact Form (Form B) will be filed with the applicant’s 		personnel file.

6.	Appropriate action will be taken by the Parish Relations Ministry based on the 			information presented.

Associated Documents and/or Forms

Form A - Employment Application Form
Form B - Reference Contact Form
Form D - Volunteer Application Form

POLICY # 5: CRIMINAL RECORDS CHECK

Peace Lutheran Church requires that all screened employees and all screened volunteers sign a release for a criminal background check.

Those Responsible for Implementation

Parish Relations Ministry

Procedures for Implementation

1.  	All screened employees and screened volunteers must read and sign the Background 		Investigation Consent Form (Form C).

2.  	A member of the Parish Relations Ministry, or designee thereof, will submit the request 		for a criminal background check. 

3.  	All forms, notes, documents and information obtained from the criminal background 		check will be kept in the applicant’s personnel file and filed for future reference by the 		Church Secretary.  This record will be considered confidential and will be kept in a 		locked file in the church office.  Only the Parish Relations Ministry Chairperson, the 		Church Secretary, and the Senior Pastor will have access to the personnel files.

4.	Appropriate action will be taken by the Parish Relations Ministry based on the 			information presented.

Associated Documents and/or Forms

Form C - Background Investigation Consent Form

POLICY # 6: APPLICANT WITH CRIMINAL SEXUAL ABUSE RECORD

It is Peace Lutheran Church’s policy that no one with a known record who has been convicted of a sexual abuse crime of any kind will be allowed to work with children.

Those Responsible for Implementation

Parish Relations Ministry

Procedures for Implementation

1.  	Upon receiving notification that an applicant has a criminal sexual abuse record, a 		member of the Parish Relations Ministry, or designee thereof, will notify the applicant 		that they will not be allowed to work with children in potentially high risk situations at 		Peace 	Lutheran Church.  At this time the Parish Relation Ministry representative, or 		designee thereof, and the applicant will complete the Notification of Ineligibility Form 		(Form E). 

2.  	Information and documents concerning the applicant’s sexual abuse record will be 		considered confidential and will be kept in a locked file in the church office.  Only the 		Parish 	Relations Ministry Chairperson, the Church Secretary, and the Senior Pastor will 	have access to the file.

3.  	Persons with criminal sexual abuse records will be encouraged to participate in minis		tries of the congregation which do not involve interaction with children.

Associated Documents and/or Forms

Form E - Notice of Ineligibility Form

POLICY # 7: TWO ADULT RULE

To ensure a safe environment for our children and to protect those who work with them 	from false accusations, Peace Lutheran Church will use a “two adult rule” for designated activities with children.

Those Responsible for Implementation

Youth Ministry (primary)
Education Ministry
Parish Relations Ministry

Procedures for Implementation

1.  	Whenever possible activities involving children will have at least two adults present in 		the church facility. At least one of the adults will be 21 years of age or older.  

2.  	Whenever possible, employees and volunteers will avoid being alone with a single 		child unless visual access by another adult is possible.  

3.	This policy recognizes that unforeseen and unplanned encounters between children 		and adults will arise.

Associated Documents and/or Forms

None

POLICY # 8: REVIEW AND TRAINING

To ensure that the Child Safety Governing Policy has been effectively implemented, members of the Parish Relations Ministry will periodically review the policy and conduct training events for the employees of the congregation and the volunteers who work with children.
.
Those Responsible for Implementation

Parish Relations Ministry

Procedures for Implementation

1.  	Once each year the Parish Relations Ministry will review the Child Safety Governing   		Policy to determine if any amendments need to be made.  If amendments are 
	necessary, the policy changes will be documented and attached to the old policy.  The 		new policy will reflect the date it was amended.  All policy changes must be submitted 		to and approved by the Church Council.  

2.  	Once each year a member of the Parish Relations Ministry will conduct a training 		meeting on child safety for the employees and volunteers of the congregation who 		work with children.

Associated Documents and/or Forms

Child Safety Governing Policy
Booklet Specifying Procedures, Forms, and Training Materials

POLICY # 9: WINDOWS ON DOORS

To provide added safety, all rooms in our church’s building, except bathrooms and storage closets, will have windows in their doors.
.
Those Responsible for Implementation

Property Ministry (primary)
Parish Relations Ministry

Procedures for Implementation

1.  	A member of the Property Ministry will conduct a periodic check of the church’s 
	building to make sure that nothing is obstructing the sight lines through the glass 		windows on all doors.

2.	A report of this check will be made to the Parish Relations Ministry by the Property 		Ministry.       

Associated Documents and/or Forms

None

POLICY # 10: VISITING ORGANIZATION USE OF THE CHURCH FACILITY

Peace Lutheran Church encourages the use of its facility by visiting organizations and opens its doors to organizations which need space for events involving children. To ensure the safety of all children, Peace Lutheran Church requires that visiting leaders abide by the Child Safety Governing Policy.

Those Responsible for Implementation

Church Secretary (primary)
Parish Relations Ministry
Education Ministry
Youth Ministry

Procedures for Implementation

1.   	Peace Lutheran Church will make available to the leaders of the visiting organization its 	Child Safety Governing Policy and the additional booklet which specifies the 
	procedures, forms, and training materials used to implement the policy.

2.  	Two representatives of the visiting organization who will be present during the 
	scheduled event must fill out the Visiting Organization Form (Form F).

Associated Documents and/or Forms

Child Safety Governing Policy
Booklet Specifying Procedures, Forms, and Training Materials
Form F - Visiting Organization Form

POLICY # 11: REPORTING AN INCIDENT

Child sexual abuse is criminal behavior that involves children in sexual behaviors as defined by state and federal law.  All employees and volunteers who work with children at Peace Lutheran Church are required to immediately report any concerns related to suspected incidents of child sexual abuse to the Parish Relations Ministry Chairperson, the President of the Church Council, or the Senior Pastor.

Types of sexual abuse that involve touching include but are not limited to:  fondling; oral, genital, and anal penetration; intercourse; and forcible rape.  Types of sexual abuse that do not involve touching include but are not limited to:  verbal comments; pornographic videos; obscene phone calls; exhibitionism; allowing children to witness sexual activity.

Those Responsible for Implementation

Parish Relations Ministry Chairperson (primary)
Senior Pastor
Church Council President

Procedures for Implementation

1.  	If sexual abuse of a child is suspected, the employee or volunteer who suspects the 		abuse is required to immediately report the suspicion to the Parish Relations Ministry 
	Chairperson, the Senior Pastor, or the President of the Church Council.  Together, the 		employee or volunteer who suspects the abuse and the responsible person contacted 		will immediately report the suspicion to the appropriate government agencies.  (See 		Policy # 12.)  

2.  	The employee or volunteer will complete Form G, Report of Suspected Incident of 
	Child Sexual Abuse, and submit this form to the Parish Relations Ministry Chairperson, 		the Senior Pastor, or the Church Council President.

3.  	In order to protect the individuals involved, all information regarding the situation will 
	be considered confidential and the employee or volunteer will only discuss the 
	situation with appropriate authorities.

4.  	All forms, notes, and documents associated with the incident will be filed and 
	considered confidential.  These records will be kept in a locked file in the church 
	office.  Only the Parish Relations Ministry Chairperson, the Church Secretary, and the 		Senior 	Pastor will have access to the file.

Associated Documents and/or Forms

Form G - Report of Suspected Incident of Child Sexual Abuse Form

POLICY # 12: GOVERNMENT REPORTING PROCEDURES

In responding to a suspected incident of child sexual abuse, Peace Lutheran Church will work with appropriate government agencies in a prudent manner to ensure the safety and dignity of the suspected victim and the person who has been accused.

Those Responsible for Implementation

Parish Relations Ministry Chairperson (primary)
Senior Pastor
Church Council President

Procedures for Implementation

1.  	The following statement comes from the Wisconsin Department of Health and Family 		Services:  “Individuals whose employment brings them into contact with children are 		required by law to report any suspected abuse or neglect or threatened abuse or 		neglect to a child seen in the course of their professional duties.  Anyone who suspects 	a child is being maltreated may make such a referral.  Persons making reports in good 		faith are immune from criminal or civil liability.  Reports are made to the county in which 	the child or the child’s family resides.”  

2.  	Employees and volunteers at Peace Lutheran Church will follow the guidelines set forth 	in procedure # 1.

3.  	Reports of suspected child sexual abuse are to be made to the county Department of 		Human Services in which the child or child’s family resides.  Reports in Polk County 		should be made to:
	
Polk County Department of Human Services
300 Polk County Plaza Suite 110
Balsam Lake, WI 54810
Office Hours: 715-485-8400
After Hours: 715-485-8300

4.  	The person or persons responsible will contact legal representation, Peace Lutheran 		Church’s insurance carrier (Church Mutual Insurance Company, Merrill, Wisconsin, 		800-554-2642), and the office of the Bishop of the Northwest Synod of Wisconsin 		(Bishop Robert Berg, Rice Lake, Wisconsin, 715-234-3373), to notify them of the report 	of suspected child sexual abuse.

Associated Documents and/or Forms

Form G - Report of Suspected Incident of Child Sexual Abuse Form

POLICY # 13: RESPONDING TO A SUSPECTED INCIDENT

Following the report of a suspected incident of child sexual abuse, Peace Lutheran Church will follow established procedures when responding to inquiries made by the 	general public, the media, and/or members of the congregation. First and foremost, these procedures will protect the rights of the suspected victim, as well as the rights of the person who has been accused.

Those Responsible for Implementation

Parish Relations Ministry Chairperson (primary)
Senior Pastor
Church Council President

Procedures for Implementation

1.	If an accusation of child sexual abuse is made, the Parish Relations Ministry 			Chairperson, the Senior Pastor, and the Church Council President will meet to 			formulate a prepared statement.

2.	This prepared statement will be used to respond to inquiries made by the general 		public, the media, and/or members of the congregation.

Associated Documents and/or Forms

None

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Employment Application Form (Form A)
(Confidential Upon Completion)

Name: ____________________________________________________________________
		Last				First			Middle

Are you over the age of 18?  _____ Yes	_____ No

Present address: ____________________________________________________________

City: ______________________________  State: ____________ Zip: __________________

Home Phone: ______________________________________________________________

Position applied for: ___________________________ Date available to start: ____________

Qualifications:
Academic achievements: (Schools attended, degrees earned, dates of completion)
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Continuing education completed: (Courses taken, dates of completion)
______________________________________________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________

Professional organizations: (List any in which you have membership)
______________________________________________________________________________________________________________________________________________________________________________________________________________________________

First aid training? ____ Yes 	____ No	Date completed: __________________________

CPR training? ____ Yes	____ No	Date completed: __________________________

Previous Work Experience: Please list your previous employers during the past five years.  Include the job title, a description of position, duties and responsibilities, the name of the company/employer, the address of company/employer, the name of your immediate supervisor, and the dates you were employed in each position.
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________________________________________________________________________

Previous Volunteer Experience: Please list any relevant volunteer positions you have held and list the duties you performed in each position, the name of your supervisor, the address and phone number of the volunteer organization, and the dates of your volunteer service.
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Have you ever been convicted of or pled guilty to a crime, either a misdemeanor or a felony (including but not limited to drug-related charges, child sexual abuse, other crimes of violence, theft, or motor vehicle violations)?  _______ No	________ Yes
If yes, please explain:
____________________________________________________________________________________________________________________________________________________

References: Please list three individuals who are not related to you by blood or marriage as references.  

1.	Name: _______________________________________________________________

	Address: _____________________________________________________________

	Day Phone: _______________________ Evening Phone: ______________________

	Length of time you have known reference: ___________________________________

	Relationship to reference: ________________________________________________

2.	Name: _______________________________________________________________

	Address: _____________________________________________________________

	Day Phone: _______________________ Evening Phone: ______________________

	Length of time you have known reference: ___________________________________

	Relationship to reference: ________________________________________________

3.	Name: _______________________________________________________________

	Address: _____________________________________________________________

	Day Phone: _______________________ Evening Phone: ______________________

	Length of time you have known reference: ___________________________________

	Relationship to reference: ________________________________________________
(Employment Application Form (Form A) page 2)

Reference Contact Form (Form B)
(Confidential Upon Completion)

Applicant name: _____________________________________________________________

Reference Name: ____________________________________________________________

Reference Address: __________________________________________________________

Reference Phone: ___________________________________________________________

1.  What is your relationship to the applicant?

2.  How long have you known the applicant?

3.  How well do you know the applicant?

4.  How would you describe the applicant?

5.  How would you describe the applicant’s ability to relate to children?

6.  How would you describe the applicant’s ability to relate to adults?

7.  How would you describe the applicant’s leadership abilities?

8.  Do you know of any characteristics that would negatively affect the applicant’s ability to 
     work with children?  If so, please describe.

9.  Please list any other comments you would like to make.

Reference inquiry completed by: ________________________________________________
					Signature				Date

Background Investigation Consent Form (Form C)
(Confidential Upon Completion)

I, __________________________________, hereby authorize Peace Lutheran Church and its agents to make an independent investigation of my background, references, character, past employment, criminal or police records, including those maintained by both public and private organizations and all public records for the purpose of confirming the information contained on my application and/or obtaining other information which may be material to my qualifications for employment now and, if applicable, during the tenure of my employment with Peace Lutheran Church.

I release Peace Lutheran Church and/or its agents and any person or entity, which provides information pursuant to this authorization, from any and all liabilities, claims or law suits in regards to the information obtained from any and all of the above referenced sources used.

The following is my true and complete legal name and all information is true and correct to the best of my knowledge:

__________________________________________________________________________
					Full Name (Printed)

__________________________________________________________________________            				Maiden Name or Other Names Used

__________________________________________________________________________
Present Address								How Long?

_________________________________________________________________________
City/State 							Zip

__________________________________________________________________________
Former Address								How Long?

__________________________________________________________________________
City/State							Zip

______________	___________________	___________________	___________
    Date of Birth	Social Security Number	Driver’s License Number	State of Issue

__________________________________________________________________________
Signature

Note:  The above information is required for identification purposes only, and is in no manner used as qualifications for employment.  

Volunteer Application Form (Form D)
(Confidential Upon Completion)
Name: _____________________________________________________________________

Address: ___________________________________________________________________

Day phone: ______________________________	Evening phone: _____________________

Occupation: ______________________________ Employer: _________________________

Previous volunteer experience with children: _______________________________________ ____________________________________________________________________________________________________________________________________________________

Special interests/hobbies/skills: _________________________________________________

Why would you like to volunteer to work with children? _______________________________
____________________________________________________________________________________________________________________________________________________

What qualities do you have that would help you work with children? ____________________ ____________________________________________________________________________________________________________________________________________________

Have you ever been charged, convicted of, or pled guilty to a crime, either a misdemeanor or a felony (drug-related charges, child sexual abuse, or other crimes of violence)?  
 ______ No ____ Yes   If yes, please explain:
____________________________________________________________________________________________________________________________________________________

References: Please list three personal references (people who are not related to you by blood or marriage) and provide a complete address and phone information for each.

1.	Name: _______________________________________________________________
	Address: _____________________________________________________________
	Day Phone: _______________________ Evening Phone: ______________________
	Relationship to reference: ________________________________________________

2.	Name: _______________________________________________________________
	Address: _____________________________________________________________
	Day Phone: _______________________ Evening Phone: ______________________
	Relationship to reference: ________________________________________________

3.	Name: _______________________________________________________________
	Address: _____________________________________________________________
	Day Phone: _______________________ Evening Phone: ______________________
	Relationship to reference: ________________________________________________

Signature: _________________________________________ Date: ____________________

Notification of Ineligibility Form (Form E)
(Confidential Upon Completion)

Applicant’s name: ____________________________________________________________

Date notified: _______________________________________________________________

Reason for ineligibility: 

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________
Signature Parish Relations Ministry Representative		Date

__________________________________________________________________________
Signature Applicant						Date

Visiting Organization Form (Form F)

Peace Lutheran Church encourages the use of its facility by visiting organizations and opens its doors to organizations which need space for events involving children. To ensure the safety of all children, Peace Lutheran Church requires that visiting leaders abide by the Child Safety Governing Policy.

Name of Organization: ________________________________________________________

Date(s) facility will be used: ____________________________________________________

Anticipated number of participants: Children __________	Adults __________

We hereby acknowledge that we have reviewed this copy of Peace Lutheran Church’s Child Safety Governing Policy, Procedures, Forms, and Training Materials.  We agree to provide a minimum of two adults for the duration of time that our organization uses Peace Lutheran Church’s facility.  

__________________________________________________________________________
Print Name of	Visiting Adult Participant # 1		Signature	                       Date

__________________________________________________________________________
Print Name of Visiting Adult Participant # 2		Signature			Date

__________________________________________________________________________
Signature Church Secretary Peace Lutheran Church		                       Date

The Church Secretary will retain this original document on file in the church office.  A copy may be provided to the visiting organization if requested.

										

Report of Suspected Incident of Child Sexual Abuse Form (Form G)

1.  Name of person observing or receiving 
     disclosure of child sexual abuse: _____________________________________________

2.  Victim’s name: ________________________ Victim’s age/date of birth: _______________

3.  Date and place of initial conversation with/report from victim: ________________________
     ________________________________________________________________________

4.  Victim’s statement (give your detailed summary here): _____________________________
      _______________________________________________________________________
      _______________________________________________________________________
      _______________________________________________________________________
      _______________________________________________________________________

5.  Name of person accused of abuse: ____________________________________________

6.  Relationship of accused to victim (paid staff, volunteer, family member, other):

      _______________________________________________________________________

7.  Date and time of report to Polk County Human Services: ___________________________
     
     Person spoken with: _______________________________________________________

     Summary of conversation:___________________________________________________ 
      _______________________________________________________________________
      _______________________________________________________________________
      _______________________________________________________________________
      _______________________________________________________________________

8.  Date and time of report to Parish Relations Ministry Chairperson: ____________________
     
     Date and time of report to Senior Pastor: _______________________________________

     Date and time of report to Church Council President: ______________________________

9.  Date and time of report to victim’s parent/guardian: _______________________________
    
     Summary of conversation: __________________________________________________
      _______________________________________________________________________
      _______________________________________________________________________
      _______________________________________________________________________
      _______________________________________________________________________

      _______________________________________________________________________
      Signature of Person Making Report 				                     	Date

Child Safety Governing Policy Training Materials

Bob sat dejectedly before the church board.  His broad shoulders slumped as he tearfully retold his story.  Bob has been sexually molesting his thirteen year old daughter for the last two years.  This activity may have gone undetected except that Bob tried to abuse one of his daughter’s girlfriends while chaperoning a Sunday School activity.  The young girl reported the incident to her parents and Bob was apprehended.  The church leaders hearing this confession sat in disbelief.  How could Bob, a successful businessman, husband, father of three children, and respected church worker commit such actions?  

Sexual abuse of children is a terrible reality of the world we live in.  The church is not immune to this reality.  At Peace Lutheran Church we want to provide a safe environment for all children and those who work with them.  Those who work directly with children and supervise other volunteers play an important role in helping prevent child sexual abuse from occurring.  This guide is designed to provide some basic training for key church workers.  The training will help workers avoid high risk situations, competently supervise volunteers, be aware of basic sexual abuse symptoms, and be aware of what to do when a suspected case of child sexual abuse is reported.

What Is Child Sexual Abuse?  

Sexual abuse in general includes any form of sexual contact or exploitation in which a minor is being used for the sexual stimulation of the perpetrator.

Sexual abuse of children may be violent or nonviolent.  All child sexual abuse is an exploitation of a child’s vulnerability and powerlessness in which the abuser is fully responsible for the actions.

Sexual abuse of children is criminal behavior that involves children in sexual behaviors as defined by state and federal law.

Sexual abuse of children includes behaviors that involve touching and non-touching aspects.  
Types of abuse that involve touching include but are not limited to:
•	Fondling
•	Oral, genital, and anal penetration
•	Intercourse
•	Forcible rape

Types of abuse that do not involve touching include but are not limited to:
•	Verbal comments
•	Pornographic videos
•	Obscene phone calls
•	Exhibitionism
•	Allowing children to witness sexual activity

What Does A  Child Sexual Abuser Look Like?

Who is the typical child sexual abuser?  Some church leaders assume that abusers are “strangers wearing trench coats” or “dirty old men.”  These stereotypes are not only inaccurate but dangerously contribute to a false sense of security.  Researchers in the field of child sexual abuse currently indicate that no one profile fits the various perpetrators of abuse.  Church leaders can become preoccupied screening stereotypes, while not suspecting the real molester could be an active adult or teen in the church.  

Symptoms Of Child Sexual Abuse

Church workers should be alert to physical signs of sexual abuse and molestation, as well as to behavioral and verbal signs that a victim may exhibit.  Some of the more common signs are listed below.

Physical signs may include:
•	Lacerations and bruises
•	Nightmares
•	Irritation, pain, or injury to the genital area
•	Difficulty with urination
•	Discomfort when sitting
•	Torn or bloody underclothing
•	Venereal disease

Behavioral signs may include:
•	Anxiety when approaching church or nursery area
•	Nervous or hostile behavior toward adults
•	Sexual self-consciousness
•	“Acting out” of sexual behavior
•	Withdrawal from church activities and friends

Verbal signs may include the following statements:
•	I don’t like [a particular church worker]
•	[A church worker] does things to me when we are alone
•	I don’t like to be alone with [a church worker]
•	[A church worker] fooled around with me

What Peace Lutheran Church Is Doing

To protect our children and those who work with them Peace Lutheran Church created and adopted the Child Safety Governing Policy.  This policy established worker screening, the two adult rule, windows on doors, child safety as part of new member orientation, ongoing review, and these worker training materials.  

What You Can Do

As an adult volunteer or employee at Peace Lutheran Church you are an essential part of this church’s efforts to provide a safe environment for our children.  The effectiveness of the child safety efforts in our congregation is reliant upon your own awareness and understanding of child safety concerns.  

The Child Safety Governing Policy should not be viewed as something which restricts the way you can do ministry but rather it should be viewed as a resource to support your efforts in carrying out your ministry in a safe manner.  It also provides you with a reasonable amount of personal protection from false accusations.           

There are several “red flags” you can watch for that might be indicative of a problem.  Watch for the symptoms of sexual abuse as they are identified on the previous page of these materials.  Avoid stereotyping who might be a potential abuser when selecting volunteers.  An adult who seems gifted and eager to work with children could be an abuser.  Identify and eliminate situations that might put you or other workers in high risk situations whenever possible.  

As an adult, it is your responsibility to notify the Senior Pastor or Parish Relations Ministry Chairperson if you feel a children’s event will place adults in potentially high risk situations with children.  This will initiate the process of screening the adults who will be participating in the event.  

When an allegation of abuse is made directly to you by either a child or another worker you must respond.  If another worker notifies you of an allegation, encourage the worker who received the report directly from the child to contact the appropriate authorities.  If that person is not willing to do so then it becomes your responsibility to make the report.  
   
It is important to understand that as an employee or volunteer with children you are empowered to use your own best judgment when it comes to the safety of our children, yourself and others who work with children.  Although you are required to follow the procedures outlined in the Child Safety Governing Policy there will most certainly be situations that are not covered by any particular procedure.  It is at these times that you must use reasonable judgment to discern what the best action to take is.  Listen to your “gut feelings”.  If something does not seem right, do not hesitate to share your concern with another adult worker or change the situation.  

Portions of these Training Materials were taken from Reducing the Risk of Child Sexual Abuse in Your Church, Church Law & Tax Report, 1993.