Child Protection Employee and Volunteer Recommitment Form

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First Presbyterian Church, Greensboro, NC

This renewal of commitment form is to be completed annually by all employees and those desiring a volunteer ministry position involving the supervision or custody of children and/or youth. It is being used to help the church provide a safe and secure environment for those children and youth who participate in our programs and use our facilities.

Employ or Volunteer Full Name *

Employee or Volunteer Address *

Employee or Volunteer Phone Number *

Employee or Volunteer Email Address *

Role in which you are completing this form (you may choose more than one) *

FPC Employee

FPC Children's Ministry Volunteer

FPC Youth Volunteer

Weekday Preschool Employee

Weekday Preschool Volunteer

Other:

Required

In the past year, are there pending, or have you been convicted of, or pled guilty or nolo contendere (no contest) to any criminal charges other than minor traffic offenses. *

Yes

If yes, please explain

Do you have any medical training and/or are you CPR certified? *

Yes

If yes, date of certification

YYYY

Is there any health related reason that would keep you from effectively working with or cause any potential harm to children? *

Yes

If yes, please explain.

Applicant's Recommitment Statement: By typing my name in this space and submitting this form, I verify that the information in this Recommitment Form is correct and complete to the best of my knowledge. I acknowledge that I have read the FPC Child and Youth Protection Policy and have received copies for my personal use. I agree to follow the Child and Youth Protection Policy and to refrain from inappropriate conduct in the performance of my services on behalf of the church. I understand that any violation of the Code of Conduct or misrepresentation of information that I have provided may result in termination of employment or volunteer service with children/youth. *

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