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Sample Screening Form

For Religious Educators and Youth Group Staff and Volunteers

Thank you for your interest in working with the children and youth of our congregation. Our congregation takes seriously our responsibility of assuring the safety of our youth.

Please fill out this form and give it to the Religious Educator. 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 with dates:

 

How long have you been attending this congregation?

 

Address/Employment

Street:

Town, State, Zip:

Number of years at current address:

If you have not lived at this address for at least 5 years, please list any previous addresses with dates:

 

 

What states have you lived in since you were 18 years old?

 

 

Home phone:

Work phone:

Place of work:

Number of years at current employment:

 

May we call your current employer for a character reference?
No ( ) Yes ( )
If not, please tell us why:

 

History

A. Have you ever been convicted of any criminal offense?
No ( ) Yes ( )
If yes, please explain:

 

B. Have you ever been accused of any crimes against a person, including rape, incest, sexual exploitation of a minor, or sexual or physical assault of a minor?
No ( ) Yes ( )
If yes, please provide details:

 

C. Have you ever resigned from employment or been disciplined or terminated by any employer for reasons related to sexual misconduct or child abuse?
No ( ) Yes ( )
If yes, please provide details:

 

D. Have you ever been convicted of any crimes against a person, including rape, incest, sexual exploitation of a minor, or sexual or physical assault of a minor?
No ( ) Yes ( )
If yes, please provide details:

 

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?
No ( ) Yes ( )
If yes, please provide details:

 

Congregation History and Prior Work with Children and Youth:

 

 

List congregations you have attended during the past five years:

 

 

Name of congregation:

City, State:

When did attend:

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 pertain to your experience with children or youth:

1) Name:

Phone:

Address:

Relationship to you:

 

2) Name:

Phone:

Address:

Relationship to you:


I authorize the congregation to contact references and other congregations to obtain information about my background regarding my character and fitness for 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.

This information will be available only to those responsible for screening staff or volunteers or participating in a response team, or as required by law.

I attest that the above information is true and correct.

Signature:

Date:

 

For more information contact safecongregations @ uua.org.

This work is made possible by the generosity of individual donors and congregations. Please consider making a donation today.

Last updated on Friday, April 22, 2011.

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