MBC Child & Youth Safety Plan
MECHANICSVILLE BAPTIST CHURCH
MBC Mission
To equip every member, of our church, to lovingly and effectively reach our community and world for Christ.
MBC Vision
To love one another in times of joy, grief, and temptation; sharing everywhere the Christian faith expressed in Holy Scripture; and making this faith evident in our individual lives, through the disciplines of the Holy Spirit.
THE PURPOSE OF THE MBC CHILD PROTECTION POLICY
Believing that God embraces children with love, placing their nurture and care in our hands, we will purpose to provide a safe and spiritually nurturing environment for children and young people. As the Body of Christ, we will support families in leading children and young people to a personal relationship with Jesus Christ. Discipleship opportunities will focus on growth in the Christian faith, the development of spiritual gifts and service to others.
Our mission is to provide an environment for our children which is safe from all forms of abuse. To be both effective and successful in these efforts, the entire congregation must understand and embrace the policies which will lead to this goal.
Table of Contents
Mission and Vision Page 1
Child Protection: Everyone’s Responsibility Page 3
Guidelines for Youth and Children Page 4
Guiding Policies for Workers with Minors Page 5
Reporting Procedures for Allegations of Child/Youth Abuse Page 8
Supervision Guidelines Page 10
General/Medical Information Form (Attachment A)
Service Application Form (Attachment B)
Driver Instructions (Attachment C)
Automobile Transportation Form (Attachment D)
Permission Form (Attachment E)
Illness/Accident/Incident Record (Attachment F)
Authorization Form for Sign-In/Sign-Out (Attachment G)
Classroom Sign-In/Sign-Out Form (Attachment H)
Record of Money Received for Trips/Activities (Attachment I)
Checklist for Youth and Children’s Activities (Attachment J)
Activity Sign-In/Sign-Out Form (Attachment K)
Consent to Background Check (Attachment L)
Mechanicsville Baptist Church
Child Protection Policy – Everyone’s Responsibility
All of your children shall be taught of the Lord, and great shall be the peace of your children. Isaiah 54:13
The Need for Child Protection
Child abuse strikes children of every age and social background. Our responsibility, in the Body of Christ, obligates us to reduce the risk of child abuse occurring while children are in our care. In order to protect and safeguard our children, youth, and staff, we will take positive steps to provide a safe environment for them.
Everyone’s Responsibility
In the Body of Christ, protecting children and youth is everyone’s responsibility. Please remember that the purpose of the child protection policy is the physical, emotional, and spiritual health of the children and youth we serve.
In addition, this process will protect those who work with children and youth from false accusations and reduce the church’s liability financially and emotionally.
The support and commitment of our Church Body are needed.
What Does This Mean To You?
Child protection policies are a normal part of systems who work with children and youth. Mechanicsville Baptist Church has developed a policy to reduce the risk of child abuse. Those who work with our children and youth on a regular basis will receive training in the expectations of the MBC Child Protection Policy. A copy of the policy will also be available in the library.
Confidentiality
The results of background checks will remain confidential. Only the pastor and youth ministry staff person or designee will have access to criminal histories. Only incidents, in one’s past, against children are needed. Other incidents in the past will not prevent participation. All records will be secured in locked files.
Training
All persons working with children and youth will be offered training in the MBC Child Protection Policy annually before the end of November. The Call to Develop a Child Protection Plan for MBC
Early in 2009, our pastor, Dr. Don Reid, called a meeting of those who might help develop a child protection plan. He suggested that such a plan would help us to be consistent in procedures and care provided to youth and children, who participate in MBC ministries.
From the original group, smaller groups were formed to discuss what might be included in the plan. We were encouraged to prayerfully engage in research and dialogue, resulting in a written document to be used in training those who are part of MBC youth and children’s ministries.
The process continued ror more than a year. The document that follows is the result of the prayerful work of a number of people. We are grateful to Dr. Reid for setting the vision before us and to all who took part in its formation. We are especially thankful to Ginny Brown, who led the proof reading, organization and final composing of the document.
The purpose of the document is to provide expectations, guidelines and procedures that support protection for the youth entrusted to us in our ministry. We believe that it is the responsibility of the entire Body to provide a safe and nurturing environment for our youth, in which they will experience love, fellowship, be engaged in learning, discipled and led to a relationship with Jesus Christ.
We are grateful for those who participated in the development of this plan:
Ginny Brown
Sherri Brown
Katie Fisher
Joyce Martin
Barbara May
Butch Morris
Barbara Morris
Marylin Riggan
Dr. Donald P. Reid
Mechanicsville Baptist Church
Guidelines for Youth and Children
The following expectations will help all of us to work together to enjoy time in Sunday School, Worship, Children and Youth Activities, Fellowship and Learning:
Show concern for our place of worship by treating it with respect—in the building and outside.
(For example: walk inside the building, clean up after your activity, speak in an inside voice)
Be in the appropriate place on time for an activity.
Follow your leader’s directions.
Take part in the activity, and do not distract other’s attention.
Focus on the activity. Leave distractions at home or have the leader put them in a safe place and return them to you when you leave
(For example: electronics, phones, toys)
Accept TIME OUT consequences if you need time to change your behavior
(TIME OUT is a temporary quiet time, away from the group. If TIME OUT does not work, you will be asked to go to your parent or the adult responsible for you.)
Understand that fellowship activities are linked to worship and service to our Lord.
When the activity is over, children 5th grade and under will be signed in and out or escorted to their parents or a parent-designated adult. Youth will go to the appropriate next place and show respect for the place and people there.
These guidelines were revised, November 2009, as part of the Child Safety focus.
Mechanicsville Baptist Church
Guiding Policies for Workers with Minors
Purpose Statement
At Mechanicsville Baptist Church we believe that the spiritual, emotional, and physical well-being of children and youth is vital. These Guiding Policies are intended to protect the children and youth, as well as those who work with them at our church. These policies will assist our congregation in providing a physically safe, emotionally secure, and spiritually nurturing environment for all participating in services or activities sponsored by MBC. These policies will apply to all who work with minors at MBC – volunteers, chaperons, and compensated workers.
General Guidelines
1. All workers with children and youth are expected to be models for Christian standards and moral behavior.
2. A minor (child or youth) is defined as anyone under 18 years of age.
3. A general information/medical form (Attachment A) will be completed on all minors.
4. All nursery or teaching settings should have a minimum of two providers; at least one will be a leader. The term provider can refer to a leader (21 years and up), assistants (18 years and up) or a junior assistant (14 years and up). If two providers are not available, the door must have a viewable observation window or remain open at all times (for details and ratios, see Supervision Guidelines). A junior assistant cannot assist with his/her own age group.
5. All adult providers will fill out a “Service Application” (Attachment B) or “Driver Instructions for Field Trips” (Attachment C) prior to beginning service. These forms and applications will be kept in strict confidence and in a locked file cabinet, accessible only to the ministerial staff and the designee.
6. A background and driving record check will be conducted on all employed and volunteer children and youth workers before service begins.
7. All youth/children leaders must be members of MBC. Non-members may be assistants or junior assistants.
8. An annual training of new youth leaders and assistants will be held by the end of November each year. Following the November training, new leaders or assistants will be provided a copy of the MBC Child Protection Policy to read and sign.
9. These policies will be reviewed annually.
10. These policies will be monitored and updated by the Children and Youth Committee and approved by Mechanicsville Baptist Church.
Guidelines for Ministry with Children/Youth:
Two-Adult Rule: At least two approved adults should be present during any church-sponsored program, event, or ministry involving children/youth. If it is not possible for two adults to be present in the same room, an adult “roamer” may monitor activity in the rooms and bathrooms. Youth may serve as the “second adult” after having completing the orientation and signing a “Child Protection Covenant” if he/she is not working with his/her own age group. A junior assistant is defined as someone who is in grades 9-12. (See Supervision Guidelines)
Open Door Policy: When there is no window in the classroom door, the door should be left open so that persons passing by can observe. When there is only one adult and one child, the door must be left open.
Parent/Guardian Permission: Parents/guardians should be well informed of the events in which their children participate. Written parent/guardian consent (Attachment E) should be obtained on a per event basis for all off-site, church-sponsored group activities. Consent should include permission to provide medical treatment.
Overnight Rule: All adult chaperones (leaders, assistants, and parents) must be approved by the MBC Children and Youth Committee before they can accompany children/youth on an overnight activity. Parent/guardian permission will be obtained for all overnight activities (Attachment E). Both male and female adult chaperones must be present at all times for overnight events if children/youth from both genders are participating. (See Supervision Guidelines)
Non-Sponsored Activities: Overnight activities for youth are sometimes held in conjunction with other organizations; therefore, MBC does not have the authority to approve all adults. MBC does not guarantee that the sponsoring organization has adopted a Child Protection Policy.
Transportation: Anyone transporting children/youth must be 21 years of age or older, hold a valid senior driver’s license, present current automobile insurance for vehicle driven , and obey all traffic laws, including use of seat belts and car seats. Youth to be transported by drivers under the age of 21 must have written permission from their parents/guardians. (See Supervision Guidelines)
Physical Discipline: No physical discipline shall be administered at any time. However, physical intervention to protect a child from harming self or others does not constitute physical discipline and may be necessary. (See Appropriate Discipline)
Arrivals and Departures
For Sunday School and Children’s Church, roll will be taken and students will only be released to parents, guardians, and other designated adults. For all other activities, a sign-in/sign-out form will be used for children in 5th grade and under. (Attachment H)
Exceptions: If a situation arises during which any of the policy goals cannot be reasonably met due to unavoidable circumstances, the adults involved should accommodate the policy as far as they are able, act in accordance with the spirit of the policy and report the situation to the Children and Youth Committee or person in charge of the ministry activity. However, it is the intent of this policy that such exceptions are rare.
Mechanicsville Baptist Church Reporting Procedures for Allegations of Child/Youth Abuse
What is child abuse and neglect?
Section 63.2-100 of the Code of Virginia defines an abused and/or neglected child as any child under 18 whose parent or other person responsible for the child’s care:
· Causes or threatens to cause a non-accidental physical or mental injury
· Neglects or refuses to provide adequate food, clothing, shelter, emotional nurturing, or health care
· Abandons the child
· Fails to provide adequate supervision in relation to the child’s age and developmental level
· Commits or allows to be committed any illegal sexual act upon a child, including incest, rape, fondling, indecent exposure, and prostitution or allows a child to be used in any sexually explicit visual material
1. All allegations of abuse will be taken seriously by the Mechanicsville Baptist Church.
· Listen supportively.
· Hear the victim out—do not minimize the allegation.
· Do not judge the allegation negatively or positively.
· Do not discuss the allegation with anyone except those who need to know in order to respond.
2. When a case of abuse is suspected, the worker will immediately insure the safety of the child, report the incident to the church member in charge of activity/event, and notify the Pastor or his/her designee. The person reporting the allegation will document all the pertinent information surrounding the event. Investigations will be handled discreetly.
3. In the event that an allegation is brought to the Children and Youth Ministry Person, the appropriate persons will be notified: legal counsel, Mechanicsville Baptist Church Insurance Carrier, and Child Protective Services.
4. Any conduct that seems inappropriate for providers is to be confronted immediately and reported to one of the following: the Pastor, the Children and Youth Ministry Person, the Sunday School Director or designee of one of these leaders.
5. In the event of an allegation against a paid church employee or a volunteer, that person will be relieved of their duties until an investigation is completed.
6. In the event that an allegation is brought against a member of the Children and Youth Committee, that person will be removed from the committee until the allegation has been investigated and resolved.
7. The parents of a child involved in an allegation of abuse will be notified immediately.
8. When necessary, leaders and family members will seek appropriate medical personnel to examine the minor as soon as possible.
9. High regard for each person’s rights, privacy, and confidentiality will be maintained at all times.
10. A spokesperson designated by the senior pastor will handle all inquiries by the media and inform the congregation, preferably using a prepared statement that will safeguard privacy, accuracy, and confidentiality.
Supervision Guidelines Supervision Guidelines
Protecting the Children As They Arrive and Depart
Arrival and Departure Times
For children kindergarten to fifth grade, leaders must be ready to accept children fifteen (15) minutes prior to the start of any session. After Sunday School, the teachers will escort the children to parents. In all other instances, parents must pick up their children immediately at the conclusion of the session. In the event that a child is not picked up within fifteen (15) minutes of the end of the session, leaders will ask an assistant to locate the parents. With the exception of Sunday School and Children’s Church, parents must sign their children in and out.
Signing a Child into Children's Ministry
For all other activities, any parent who would like his/her child to participate in a children's ministry program will sign the child in to the appropriate classroom, nursery, or activity when he/she arrives, granting permission for the child to participate in the MBC event or program. This sign –in will authorize MBC to secure medical services for the child in the event of accident or injury if the parents or legal guardians are unavailable. The parent should also use this opportunity to note any allergies or special needs the child may have (Attachment H).Parents can authorize other adults or siblings to pick up their child (Attachment G).
Protecting the Children While They Are in Activities
Roamers
The roamer is a qualified caregiver whose duties are not limited to any one
classroom. He or she is responsible for making classroom checks for safety and assistance. Roamers generally move about the hallways and building during the scheduled session times to observe any unusual activity and to be of service to the other caregivers (e.g., locating parents or substituting temporarily for another caregiver). A roamer is on-duty during the regular scheduled meetings at the church.
Greeter
The greeter, (Sunday School secretary or a designee) will greet new children at the bottom of the Sunday School stairs and escort them to the appropriate class. The teacher/leader will obtain information about the child (Attachment A).
Child-to-Caregiver Ratio
In addition to always having two (2) caregivers present, the following ratios are
maintained.
· 1 adult leader and 1 assistant for the first twenty or fewer children or youth
· 1 additional assistant or junior assistant for each additional ten children or youth
(For example, 27 youth would require 1 leader and 1 assistant)
The Director of Children/Youth Ministry or Roamer should be notified if more caregivers are needed in order to maintain these ratios.
Supervision Guidelines continued
Playground Rules
These rules will be posted in the building and on the shelter for parents to view.
1. Use playground equipment at your own risk. Parents are responsible for supervision of their children.
2. Playground equipment is intended for 8-years-old and younger.
3. Stay away from swings when children are swinging.
4. Only SIT on swings.
5. One person at a time climbs the slide ladder. Only come down slide in a SITTING position. DO NOT walk up the slide.
6. Do not jump off equipment.
7. No pets allowed in mulched area.
8. No horseplay on or near equipment
9. All running will be away from playground equipment.
10. Clean up area after use.
During activities, leaders supervising the children on the playground will ensure guidelines are followed. When an activity is not in session, it is the parent’s responsibility to supervise their children.
Rest Room Procedure
Nursery: A female leader or assistant will take the child to the restroom. Only parents/guardians will change diapers unless that parent has given permission on the sign-in form. If necessary, parents will be notified to change diapers. Nursery workers will not change them.
Children I (K-2nd grade): Children are encouraged to use the bathroom prior to the activity. In the event of an emergency, the teacher will send either 2 children or 1 adult and 1 child. If a child needs assistance, a female leader will assist him or her.
Children II (3rd-5th grade): Children are encouraged to use the bathroom prior to the activity. In the event of an emergency, the teacher will use his or her discretion and will either send the child alone or with a same-sex peer.
Youth I &II - Youth are encouraged to use the bathroom prior to the activity. In the event of an emergency, the teacher will send the child alone.
Snacks
Snacks are sometimes served in the activities. Parents are responsible for notifying caregivers of any food allergies or other health issues.
Appropriate Discipline
All leaders, assistants and church members are responsible for providing a loving, respectful and orderly atmosphere in which children can learn, play and interact with others. This atmosphere should be maintained by:
· Preparing beforehand
· Proactively directing children towards acceptable behavior
· Verbally encouraging positive behavior
· Correcting or redirecting inappropriate behavior when necessary
Acceptable means of redirecting inappropriate behavior include
· Correcting the child verbally
· Withholding a certain privilege or activity for a brief time
· Separating the child from the group for a brief time
If the behavior cannot be redirected, the parent or responsible adult will be contacted and possibly will be asked to remove the child.
If the behavior has been deemed dangerous to the child or others, the parent will be asked to remove the child. If the child is removed for disciplinary reasons, the youth leader will meet with the parent and child.
Accidents and First Aid
All classrooms are equipped with institutional first aid kits. Leaders and assistants should be familiar with their contents and uses. In the event of a life-threatening injury or illness, emergency medical services will be called first and an assistant will locate and inform the parents immediately. The leader or assistant will notify the parents of any minor injury, illness, or accident. If the situation is significant, the youth leader or assistant will fill out the Accident/Illness/ Injury Report (Attachment F), have the parent sign it and give it to the Director of the program (Sunday School, VBS or Children &Youth).
Protecting Children during Travel Activities
1. Adult chaperones (leaders or assistants) for activities involving travel will include men if boys attend the event and women if girls attend the event. The ratio of chaperones to children will be 1 to 5, and chaperones to youth 1 to 10.
2. A sign in/list of all attendees will be kept. (Attachment K).
3. Children must have an adult sign them in and a supervising adult must sign them out when they leave. Children must remain with a supervising adult until released to the adult who is taking them home.
4. Youth can sign themselves in but the supervising adult must sign them out when they leave.
5. The Children and Youth Committee prefers to receive permission forms at least 5 days prior to the day of the trip to have time to arrange chaperones and drivers. The forms must be received 48 hours before the event. All information must be completed. Copies of completed forms are to be left, in an envelope or folder, on the church secretary’s desk, 5 days prior to the activity. The information will remain confidential and kept in a secure location, at church, to be accessed in case of an emergency. (Attachment E)
In addition to copies of the permission forms, the following information will be provided to the church office.:
-the destination, directions for driving there, address, phone number, contact person at the destination (Attachment C)
-emergency phone numbers of at least 2 adults chaperoning the group.
-a list of all drivers, copy of each driver’s license and insurance cards
(Attachment D)
-Drivers will be at least 21 years of age, unless driving themselves or with permission of their parents/guardians.
-a list of participants riding in each vehicle (Attachment C)
-a list of money received for participants (Attachment I)
This means chaperones and people providing transportation will have to be arranged AT LEAST 5 days prior to the activity. (Children/Youth Leader Checklist for Activities, see Attachment J)
Drivers and chaperones are to have a LIST of those they are transporting and/or/supervising and copies of permission forms with emergency information. Immediately after the trip, the leader will collect permission forms from the drivers.
6. Any medications must be in the original container, with the physician’s instructions for administering. Youth leader will have the medications in her possession at all times and administer them per the physician’s instructions. She will keep a log of the date/time medications are administered. Inhalers and epi pens may be kept by the owner unless the parent or physician states Youth leader is to keep them.
7. Upon return from the trip the Children & Youth Ministry person will be responsible for seeing that all equipment, supplies and participant’s possessions are put away or removed from the building/shelter/church yard, with responsibility for returning all lost/found items immediately.
8. It is expected that the Children & Youth Ministry person will be responsible for informing and leading participants in following the MBC Guidelines for Youth and Children.
9. Driver will have emergency forms from all passengers. Leaders will have copies of emergency forms for all participants.
10. If a child needs to be transported home after an activity because a parent/guardian was unable to come, permission to transport must be documented and should include documenting person, date, time, means of communication, persons giving and receiving information.
Overnight Supervision
1. All travel guidelines will be followed unless redefined in this section.
2. Written permission from parents/guardians of child or youth involved will be secured according to travel guidelines.
3. At least two chaperones must be on site at all times. Ratios should be as follows: 1:10 for Senior High, 1:8 for Junior High, and 1:5 for children. One adult 21 years or older of each gender must be on site at all times for groups with both genders.
4. No child or youth will leave the location or activity, except with parent, guardian or parent or guardian designated person (in writing).
5. Sleeping arrangements must be gender separated. At least one adult chaperone, of the same gender, must be with each group in sleeping arrangements.
6. When camping, an adult will periodically check on campers.
7. When booking hotel rooms, advance request must be made to book rooms in close proximity, on the same floor if possible. Chaperones will keep possession of room keys, as well as a list of room numbers for Children/Youth/Chaperones participating in the activity.
8. Minors will not be unsupervised nor have access to rooms without adult supervision.
9. All participants must be informed of safety and security measures for the activity location.
ATTACHMENTS
Forms
(Attachment A)
Mechanicsville Baptist Church
General/Medical Information Form
CONFIDENTIAL
(Please print clearly)
Name__________________________________________________________________
Date of Birth (MMDDYY) __________________Age_______ Male ____ Female ____
Address _______________________________________________________________
Parent/Guardian_______________________________ Phone___________________ Bus. Phone________________ Cell Phone ____________________
Parent/Guardian_______________________________ Phone____________________ Bus. Phone________________ Cell Phone ____________________
Emergency Contact other than parents_______________________________ Phone____________________ Cell Phone ____________________
Family Physician____________________________ Phone ____________________
Dentist ___________________________________ Phone _____________________
Any chronic health problems that limit physical activity? Yes_____ No_____
If YES, list problems________________________________________________________________
________________________________________________________________________
Currently taking any medication? Yes____ No____. If YES, please give name of drug and condition:
________________________________________________________________________
Any allergies? Yes____ No____. If YES, please explain__________________________________________________________________________________________________________________________________________
Date of last tetanus shot __________________________
Recent health problems that we should be aware of ________________________________________________________________________
Do you give permission for your child to receive CPR from a certified person if necessary? Yes ______ No _____________
Medical Release
I release Mechanicsville Baptist Church from responsibility and liability for any injury or illness that my child may sustain during this activity. I authorize the Mechanicsville Baptist Church Staff to act, as agent, for me to consent to any emergency medical treatment and hospital care advised and supervised by a physician, surgeon or dentist. I expect to be contacted as soon as possible.
Signature of Parent/Guardian_______________________________________________-
Date________________________________
Child/Youth’s Medical Insurance Company__________________________________
Policy Number___________________
______________________________________________Signature __________________________Date
(Attachment B)
Mechanicsville Baptist Church
10200 Louisa Road Gordonsville, Virginia 22942 Phone: 540 832 2813
Service Application
(Please print clearly)
Confidential: This information will be treated as strictly confidential. Only those persons having a legitimate need to know such information will have access to this form.
Date: ______________
Name: ______________________________________Phone: ______________________
Address: ________________________________________________________________
City: ___________________________ State: ________________ Zip: ____________
Marital Status: _______________ Email: ____________________________________
Members in household (including ages of any children): ________________________________ ________________________________
________________________________ ________________________________
________________________________ ________________________________
________________________________ ________________________________
Present Employer: _______________________________________________________
Address: ________________________________________________________
Work Telephone # _______________________________
Do you have any training/experience which equips you for a special area of ministry?
Please explain:
Do you have any hobbies and/or interests that you would want to share?
List all previous activities involving working with children or youth:
(Attachment B continued)
Service Application (p. 2)
How long have you been attending the Mechanicsville Baptist Church?
Membership status: ( ) member ( ) non-member
List previous churches attended regularly in the past five years:
List any previous and current ministry involvement with the Mechanicsville Baptist Church:
Please give a brief testimony as to when and how you came to know Jesus Christ as your Savior and Lord:
Have you ever been investigated, accused, or convicted of child abuse? _____________
If yes, please explain:
Please list individuals outside of your family and the church pastoral staff who can be personal references and / or comment on your past interaction with minors (optional for those attending Mechanicsville Baptist Church more than two years). These persons may be contacted by us.
1. Name of Reference _____________________________ Phone: _________________
Relationship to you: ___________________________________
2. Name of Reference _____________________________ Phone: _________________
Relationship to you: ___________________________________
(Attachment B continued)
Service Application (p. 3)
Child Protection Covenant
I accept the call to serve the Lord through working with children or youth
at Mechanicsville Baptist Church.
I know that I follow Jesus’ example when I value children and youth
and care for them with love and gentleness.
I recognize the importance of the responsibility entrusted to me.
I realize that my words and actions toward children and youth will influence their faith in God and their lives for many years to come.
I promise to be responsible in all of my attitudes and actions, especially toward the children or youth under my care.
I have carefully read and agree with this congregation’s “Child Protection Policy.”
I attest that I have never been charged with nor convicted of child abuse, contributing to the delinquency of a minor, or any other criminal conduct related to children or youth or to physical or sexual misconduct.
I attest that I will not engage in any inappropriate contact with children or youth –
I will not abuse anyone physically, sexually, or emotionally. I will not engage in any unbecoming conduct.
I covenant and promise to be a good example to the children or youth entrusted to my care. I will pray and study God’s Word regularly, and do my best to reflect God’s love to them.
I accept the responsibility of my ministries to children or youth with gladness, and I will strive to honorably fulfill my responsibilities with integrity.
With the prayers and encouragement of the members of the Mechanicsville Baptist Church, with the support pledged to me, and with God’s guidance, I am committed to serve in ministry to children or youth.
(Attachment B continued)
Service Application (p. 4)
Please sign the following statement: I hereby declare that the information contained in
this application is correct to the best of my knowledge. I also authorize a representative of the MBC Children and Youth Committee or their Designee to contact any individuals or organizations listed in this application and authorize those individuals or organizations to provide the information requested. I release them and the Mechanicsville Baptist Church from liability for doing so. If required, I will assist the Mechanicsville Baptist Church to obtain a Criminal Record Check and Child Abuse History Clearance on me. Additionally, I declare that I have read the MBC Child protection Policy and the Child Protection Covenant and agree to follow all of the expectations written there.
Signature ________________________________________ Date: _________________
Print Full Name _________________________________________________________
(Attachment C)
Mechanicsville Baptist Church
Driver Instructions for Field Trips
(Please print clearly)
DRIVER INSTRUCTIONS
1. You possess a current valid driver’s license
2. You affirm that you currently do NOT have 2 or more points assigned by DMV on your driving record.
3. You have completed the MBC Transportation Form and certify that you carry at least $100,000 per occurrence worth of liability on your vehicle.
4. You will check the safety of your vehicle’s tires, brakes, lights, horn, suspension, etc. before you embark on the trip.
5. You will carry only the number of passengers, for which your vehicle was designed, not in any case to exceed 10 people.
6. If your vehicle is a truck, or pick-up truck, occupants shall only be carried in the passenger compartment.
7. All occupants must wear seatbelts.
8. In case of an emergency, the driver will keep all of the Children/Youth together, call 911 first, and then call the church or church’s designated person.
9. Youth under the age of 12 will not sit in the front seat.
10. All children and youth must use age-appropriate safety restraints (booster seats, seat belts, car seats).
I certify that I have not been convicted of reckless driving or driving, under the influence of drugs or alcohol, within the past 5 years and that the information, given above, is true and correct. If requested, I would submit to a drug test. I understand that, if an accident occurs, my private insurance coverage shall bear primary responsibility for any losses or claims for damages. I hereby waive all claims against Mechanicsville Baptist Church for injury, accident illness or death occurring during or by reason of this field trip or excursion.
Driver’s Name_________________________
Driver’s Signature_____________________________ Date____________________
(Attachment C continued)
Driver Instruction continued
Destination ___________________________________________________________
Departure Time _______________________________________________________
Departing From _______________________________________________________
Passengers for this vehicle:
1.
2.
3.
4.
5.
6.
7.
Directions to destination ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Emergency cell numbers to contact person in charge of trip
_____________________________________________________________________
(Attachment D)
Mechanicsville Baptist Church
Automobile Transportation Form
(Please print clearly)
Driver (circle one) Employee Parent/Guardian Volunteer
Name_________________________________ Birth date _____________________
Address_________________________________________________________________
Street or P.O. Box City, State, Zip Code
Phone Numbers ______________________________________________________________________
Home Cell Emergency Contact
Driver’s License Number_____________________ Expiration Date_________________
Vehicle Information
Owner_______________________________________________
Owner’s Address: ________________________________________________________
Street or P.O. Box City, State, Zip Code
Make of vehicle ___________________________Year of vehicle___________________
License Plate Number______________________ Seating Capacity________________
Registration Expiration Date__________________
Insurance Information
Insurance Company___________________ Phone Number_______________________
Policy Number________________________ Policy Expiration Date________________
What are your liability limits?______________________________________________
Must carry at least $100,000 policy
Please attach copies of current driver’s license and insurance card.
(Attachment E)
Mechanicsville Baptist Church
Permission Form
(Please print clearly)
Name of Child/Youth_____________________________________________ Gender: M F
Phone Numbers ________________________________________________________
Name Home Cell Work
Email Address for Parents/Guardians________________________________________________________
911 Street Address_________________________________________________________________
________________________________________________________________________
Child/Youth’s Birth date _______________________ Current Grade Level___________
Month Day Year
I give permission for the above named Child/Youth to join and participate in Mechanicsville Baptist Church’s
Children/Youth Activity: ___________________________________________________
On (date)____________________
Month Day Year
Signature of Parent/Guardian________________________________ Date ___________
Emergency Contacts
Name ________________________________ Relation______________
Phone ________________ home ___________________ cell __________________work
Name ________________________________ Relation______________
Phone ________________ home ___________________ cell __________________work
Medical Release
I release Mechanicsville Baptist Church from responsibility and liability for any injury or illness that my child may sustain during this activity. I authorize the Mechanicsville Baptist Church Staff to act, as agent, for me to consent to any emergency medical treatment and hospital care advised and supervised by a physician, surgeon or dentist. I expect to be contacted as soon as possible.
Signature of Parent/Guardian_______________________________________________- Date________________________________
Doctor/Dentist_________________________ Phone __________________________
Child/Youth’s Medical Insurance Company__________________________________
Policy Number___________________
Medications being taken _____________________________________
Any medications, to be administered during the activity, must be in original containers, with physician’s directions and kept by a supervising adult at all times.
Allergies/Handicaps/Limitations____________________________________________________________________________________________________________________
(Attachment F)
Mechanicsville Baptist Church
Illness/Accident/Injury Report
Name of Child: ______________________________________________________________
Check ONE
□ Illness (complete Sections A, D, E)
□ Accident (complete Sections B, D, E)
□ Incident involving child (complete Sections C, D, E)
Ministry or activity in which the child was involved: ____________________________________________
Complete appropriate section
Section A – Illness
Date: _____________________ Time Commenced: __________________________
Nature of illness ______________________________________________________________________
________________________________________________________________________
Section B – Accident
Date of Accident: ____________________ Time of Accident: _____________________
Nature of injury: _________________________________________________________
________________________________________________________________________
Activity during which accident occurred: _________________________________________________________
Supervisor of activity: _________________________________________________________
Others leaders present: _________________________________________________________
Section C – Incident
Date of incident: ___________________Time of incident: _______________________
Describe the incident in detail: ______________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
(Attachment F continued)
Section D – Treatment or Care Provided
Describe in detail how the child was treated or the situation was handled: ________________________________________________________________________________________________________________________________________________________________________________________________________________________
Section E – Notification and Signatures
Was parent/guardian notified? _____ Yes _____ No
Name of parent/guardian notified: __________________________ Time: ____________
Name and signature of person supervising at the time:
Name: ________________________________ Signature: ________________________
Name and signature of staff member:
Name: _______________________________ Signature: _________________________
(Attachment F Continued)
Mechanicsville Baptist Church
Injury/Illness Report
Date ___________________________ Time _____________________________
Dear Parent or Guardian:
Here is what happened with your child today: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
We treated it by:
________________________________________________________________________________________________________________________________________________________________________________________________________________________
Sincerely,
_________________________________
Staff Member
We welcome any comments or suggestions you may have, regarding our programs. Please feel free to observe the class interaction at any time.
(Attachment G)
Mechanicsville Baptist Church
Authorization Form for Sign-In/Sign-Out
Date: ___________________________________ Birth Date _____________________
Name of Child _________________________________ Age _____________________
Parent(s) Name(s) ______________________________________________________________
(Please print)
Parent(s) Signature __________________________________________________________
Please list below all persons to whom you give permission to sign your child in and out of a Mechanicsville Baptist Church activity. A (Please print):
Print Name Relationship Driver(Y or N)
__________________________________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________(Attachment H)
Mechanicsville Baptist Church
Nursery Sign-In/Sign-Out Form
(Please print clearly)
DATE CHILD’S NAME PARENT SIGN IN PARENT SIGN OUT ALLERGIES PERMISSION TO CHANGE DIAPERS
(Attachment I)
Mechanicsville Baptist Church
Record of Money Received for Trips and Activities
(Please print clearly)
Activity Date __________________________________________
Activity_______________________________________________
Person(s) Receiving Money ______________________________
Participant Amount Rec’d Date Check Cash
(Attachment J)
Mechanicsville Baptist Church
Checklist for Youth and Children’s Activities
Initial Planning with Pastor, Y&C Committee, any other committees
Dates/Times cleared with Coordinating Council, church secretary
Arrangements booked with destination, written costs and reservations received
Permission Forms and Information Sheets printed
Written information given to secretary for bulletin
Written information and permission forms given to parents/guardians
All copies of drivers’ licenses and insurance forms collected & filed
List of chaperones, drivers and riders completed
All permission forms received, copied and given to appropriate drivers
All money collected, listed on form; money given to church treasurer
Check received from church treasurer or information for check to be sent to vendor
After activity—sign in/out forms filed in church office
Person in charge of activity or trip collects emergency forms from drivers
All lost/found items, equipment, supplies returned, area clean
Chaperones and drivers listed below (please designate which):
(Attachment K)
Mechanicsville Baptist Church
Children and Youth Activity Sign-In/Sign-Out Form
(Please print clearly)
Activity Date_____________
Activity ______________________________________________
Location of Activity ______________________________________
List ALL participants.
Participant Adult Sign-In Adult Sign-Out
(Attachment L)
Mechanicsville Baptist Church
Consent for Criminal Background and Driving Record Check
I hereby give my permission to Mechanicsville Baptist Church, in Gordonsville, Virginia, to obtain information relating to my criminal history and driving record. The criminal history and driving record, as received from the reporting agencies, may include arrest and conviction data, plea bargains, deferred adjudications, and delinquent conduct committed as a juvenile. I understand that this information will be used, in part, to determine my eligibility for a volunteer/paid position with this organization. I also
understand that as long as I remain a paid/volunteer employee here, the criminal history and driving records check may be repeated at any time. I understand that I will have an opportunity to review the criminal history and driving records as received by Mechanicsville Baptist Church, and a procedure is available for clarification if I dispute the record as received. I also understand that the criminal history and driving record could contain information presumed to be expunged.
I, the undersigned, do for myself, my heirs, executors and administrators, hereby remise, release and forever discharge and agree to indemnify Mechanicsville Baptist Church, and each of their officers, directors, employees, and agents and hold them harmless from and against any and all causes and actions, suits, liabilities, costs, debts and sums of money, claims and demands whatsoever, including claims for negligence, gross negligence, and/or strict liability of Mechanicsville Baptist Church and any and all related attorneys’ fees, court costs and other expenses resulting from the investigation of my background in connection with my application to become a volunteer/paid staff member.
Signature of applicant Date
_________________________________ ___________________
Printed full name of applicant
_______________________________________________________________________
First Middle Last (Maiden)
Birth date
_______________
(Attachment L continued)
Dispute of Criminal Background Check
(Please Print)
Name: __________________________________________________________________
Please provide a written response to the results of your background check and/or driving record. Your responses will be reviewed by the pastor and the Children and Youth ministry person. A meeting to discuss the dispute will be scheduled. In the absence of the pastor, a deacon designee will attend the meeting.
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
______________________
Signature
______________________________
Please print name