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Safe Conduct Volunteer Screening Form



This form is to be completed every three (3) years by all people offering their time and talents to volunteer with children, youth, or Caring Ministries recipients at First Church ofChrist, Congregational, Glastonbury, Connecticut (the “Church”). It is being used so that the Church can provide a safe and secure environment for the children, youth and adults who participate in the life of the congregation. The information you provide is confidential. The completed form will be kept in a locked file in the Church office and access to it will be restricted to ordained staff, any applicable program staff and the Church President or his/her designee(s).



Full name
Check One:
Termination or the outcome of the situation with explanatory comments:
Involving you or your background that would call into question your being entrusted with the supervision or care of children, youth, the elderly or infirm?

1 “Sustained” means:

1) a guilty plea, a guilty verdict or a plea bargain has been entered by you in a criminal court;.

2) a judgment has been entered against you in a civil court; and.

3) an accusation is being investigated by a special disciplinary committee or charges have been filed but have not yet been decided by a permanent judicial commission or an equivalent state or process in a church ecclesiastical case.

The information I have provided above is correct to the best of my knowledge, and I certify that I will immediately notify ordained staff and any applicable program staff if my certification requires amendment or revision during the three years it is maintained by the Church. I will provide references if requested and hereby authorize First Church to check any such references and past church involvements if deemed necessary, to perform any other background check deemed necessary and appropriate and to place the information they find in my file. I authorize any previous employer, and any law enforcement agencies or judicial authorities or ecclesiastical governing bodies to release any and all relevant information related to issues of misconduct and abuse to the Church.

I have read and I agree to abide by the Safe Conduct policy and applicable guidelines ofFirst Church of Christ, Congregational, in Glastonbury, Connecticut.

First Church of Christ, Congregational, UCC is committed to promoting a safe, open and spiritually healthy environment. We strive to protect our congregation from the occurrence and/or allegations of misconduct and all abuse through education of our congregation, screening our employees and volunteers and fostering an increased awareness of issues of misconduct. A copy of the First Church Safe Conduct Policy is available from the Church office, the ordained staff or the Church President.

By submitting this form, you accept the Mollom privacy policy.