Safe Sanctuaries Questionnaire (Annual)

Questionnaire

Have you ever filled out a questionnaire for this church?

Yes No

If yes, give the approximate date:

Have you ever been accused, in a written & signed statement, of sexual misconduct with a child/youth?

Yes No

Have you ever been accused, in a written & signed statement, of sexual misconduct with an adult?

Yes No

Have you ever been dismissed from any position, volunteer or salaried, because of accusations of sexual misconduct on your part?

Yes No

Have you ever resigned from any position, volunteer or salaried, because of an accusation of sexual misconduct on your part, or to avoid being dismissed because of an accusation of sexual misconduct on your part?

Yes No

Have accusations of sexual misconduct on your part (as the instigator, NOT the victim) ever resulted in civil or criminal court proceedings at any level (e.g., indictment, arrest, trial, etc.)?

Yes No N/A

Have accusations of sexual misconduct against you resulted in civil or criminal court proceedings on more than one occasion?

Yes No N/A

In addition, 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 young people?

Yes No

If you answered “yes” to questions #2-7 (any or all), please explain fully and in writing.

I understand that completion of this form authorizes Hunt’s Church to re-run a background check for the duration of my service.

Yes No

Covenant Statement

Hunt’s Church is committed to providing a safe and secure environment for all children, youth, volunteers and staff who participate in ministries and activities sponsored by the church. Our Safe Sanctuaries Policy reflects our commitment to ensure that our church is a safe and holy place in which all people can experience the love of God through relationships with others. No adult who has been convicted of any form of child abuse should volunteer to work with children or youth in any church-sponsored activity. By signing this Participation Covenant (entering my name digitally below), I agree to observe and abide by Hunt’s Church’s Safe Sanctuaries Policy acknowledge their availability on the church website (www.huntsumc.org). I verify the answers I have provided on this Questionnaire are true and accurate to the best of my ability. I understand that false answers, as well as failure to sign this Response Form, will result in my being denied the position for which I am being considered.

Name

Date Completed

Safe Sanctuaries Questionnaire (Annual)

Description

Please Fix the Following