A serious complaint or allegation, now under review, has been made about you to the Northwest Safe Congregation Response Group. While this complaint is being investigated, in order to protect the children and youth in our programs from potential risk, and in order to protect you from further suspicion, we ask you to abide by this interim agreement. Signing this document in no way constitutes a presumption or confession of guilt. This is a routine safety precaution, activated without prejudice toward particular individuals or circumstances. This document will be made known only to the Board President, Minister, the Director of Religious Education and the members of the Response Team It will be kept in a locked file in the Minister’s office.
Within these guidelines, the congregation welcomes your participation in adult worship services, coffee hour, committee meetings, adult education, all adult social events, and well-supervised intergenerational events. You are to avoid all contact with children on congregation property or congregation-sponsored events.
This includes the following while these allegations are under investigation:
I accept that the following people will be told of my circumstances in order for them to protect the children/young people for whom they care: Minister, DRE, Board President and members of the Response Group.
I have reviewed this covenant and agree to abide by its provisions. I understand and agree that if I violate this agreement, I will be denied access to future NW functions and NW property.
I understand that this contract will be reviewed regularly every six months and will remain for an indefinite period if the allegations are found true.
Signature & Date
Board President & Date
Minister & Date
DRE, if applicable & Date
The NWUUC of Sandy Springs affirms the dignity and worth of all persons. We are committed to being a religious community open to those who are in need of worshipping with us, especially in times of serious personal troubles. However, based on your background, we have concerns about your contact with children and youth in our congregation. The following guidelines are designed to reduce the risk to both you and them of an incident or accusation. We welcome you to our congregation and our membership but your participation will be limited to ensure the safety of our children and youth and to assure that you will not be subject to future accusations.
Within these guidelines, the congregation welcomes your participation in adult worship services, coffee hour, committee meetings, adult education, all adult social events, and well supervised intergenerational events. You are to avoid all contact with children on congregation property or congregation-sponsored events.
This includes the following:
I accept that the following people will be told of my circumstances in order for them to protect the children/young people for whom they care: Minister, DRE, Board President and members of the Response Group.
I have reviewed this covenant and agree to abide by its provisions. I understand and agree that if I violate this agreement, I will be denied access to future NW functions and NW property.
I understand that this contract will be reviewed regularly every six months and will remain for an indefinite period.
Signature & Date
Board President & Date
Minister & Date
DRE, if applicable & Date
LIMITED ACCESS AGREEMENT – CONFIDENTIAL
Thank you for your interest in working with the children and youth of our congregation. Our congregation takes seriously the responsibility of assuring the safety of our youth. Please fill out this form and give it to the director of religious education. Thank you for your support in providing a safe and secure environment for all of the congregation’s children and youth.
Name
First:
Middle:
Last
Have you ever used a different name? No Yes If yes, please list the dates:
How long have you been attending this congregation?
Home Address:
Number of years at current address?
If you have not lived at this address for at least five years, please list any other addresses over the last five years with dates:
What states have you lived in since you were 18 years old?
Home Phone:
Work Phone:
Number of years at current employment
May we call your current employer for a character reference? Yes No If not, please tell us why
A. Have you ever been convicted of any criminal offense? Yes No If yes, please explain on an attached piece of paper if necessary. B. Have you ever been accused of any crimes against a person, including rape, incest, sexual exploitation of a minor, sexual or physical assault of a minor? Yes No If yes, please provide details on an attached piece of paper if necessary. Have you ever been accused of sexual misconduct or child abuse? Yes No
If yes, please provide details on an attached piece of paper if necessary :
D. Have you ever been convicted of any crimes against as person, including rape, incest, sexual exploitation of a minor, sexual or physical assault of a minor? Yes No If yes, please provide details on an attached piece of paper if necessary:
E. Other than the above, is there any fact or circumstance involving you or your background that would call into question your being entrusted with the supervision, guidance, and care of children and youth? Yes No If yes, please provide details on an attached piece of paper if necessary:
Congregation History and Prior Work with Children and Youth List congregations you have attended during the past five years.
Name of Congregation City, State Dates Name of Congregation City, State Dates Name of Congregation City, State Dates
List all previous work involving children and youth (list name, type of work performed, person you were responsible to)
Please list two references who are not relatives who have known you for at least three years and who are familiar with your character as it pertains to your experience with children or youth.
Name (1):
Address:
Phone:
Relationship to you
Name (2):
Address:
Phone:
Relationship to you
I authorize the congregation to contact references and other congregations to obtain information about my background regarding my character and fitness to work with children and youth. I authorize references to provide such information about me. I hereby release and hold harmless from liability any person or organization that provides information. I also agree to hold harmless this congregation, its trustees, employees, and volunteers.
Further, I understand that a member of the staff may check the sex offender registry and/or contact the local police for more information about my background. I give permission for a background check in my state.
This information will be available only to those responsible for screening staff and volunteers or participating in a response team, or as required by law.
I attest that the above information is true and correct.
Signature & Date
Adults and older youth who teach and/or lead our children and youth play a key role in fostering the spiritual growth and character development of our children and youth. It is therefore especially important that those in leadership positions provide the special nurture, care, and support that will enable our children and youth to develop a positive sense of self and a spirit of independence and responsibility. Therefore, those who teach and/or lead our children/youth will:
Leaders shall be informed of the Code of Ethics and agree to it before assuming their role. In cases of violation of this code, appropriate action will be taken. I have read the above Code of Ethics and understand that they govern expected behavior of those working with the children and youth at Northwest Unitarian Universalist Congregation.
Name Printed
Signature & Date
Today’s date:
Date/Time of incident:
Name of person who initiated this report:
Name and title of worker or volunteer observing or receiving disclosure of abuse:
Victim’s name:
Victim’s age/birth date:
Date/place of initial conversation with or report from victim:
Victim’s statement (give your detailed summary here):
Name of person accused of abuse:
Relationship of accused to victim (paid staff, volunteer, family member, other): Reported to minister/DRE (state one):
Date/time:
Summary:
Call to victim’s parent/guardian/family member
Date/time:
Spoke with:
Summary:
Call to Department of Human Services – 24/hr abuse report hotline Date and time
Spoke with:
Summary: