EMPLOYEE AND VOLUNTEER RE-COMMITMENT FORM

EMPLOYEE AND VOLUNTEER RE-COMMITMENT FORM

ATTACHMENT 3
This renewal of commitment form is to be completed annually by all employees and volunteers involved in 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.
Part 1: Changes to Contact Information (Address, Phone, or Email)
Name*

First NameMiddle NameLast Name
Date*

MonthDayYear
Date
Has your mailing address, phone number, or email address changed in the past year? If yes, please list new address, phone number, and/or email address below:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Which phone number changed?
Is it okay to send you text messages on your cell phone?

YesNo
Email
example@example.com
Do you have any updated medical training?
Are you CPR certified?
Part 2: Personal Status Changes
Have there been any changes in the past year to any of the following?
1. Substance abuse: alcohol, tobacco or other drugs?*
If yes:

ChargedConvicted
2. Criminal behavior: Felony or Misdemeanor?*
If yes:

ChargedConvicted
3. Child abuse or neglect:*
If yes:

ChargedConvicted
If yes to any of the above, please elaborate:
Please describe and state what steps you have taken to correct the problem:
4. Is your Driver's License current and valid?*
5. Do you currently have vehicle insurance coverage as required by the State of North Carolina?*
I understand that it is my responsibilty to notify the head pastor if there are issues of a delicate matter that arise during the current year.
Signature*

Clear
Date

MonthDayYear
Date
Part 3: Applicant's Re-Commitment Statement
The information provided in this Re-Commitment Form is correct and complete to the best of my knowledge, and I acknowledge that I have reviewed and received the FPC Child and Youth Protection Policy, Attachment 2 - Summary of Points.

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 and/or youth.

I have reviewed and received a copy of the FPC Newton Child Protection Policy, Attachment 2 - Summary of Points during a teacher/leader training, or during a review with a staff person this year.
Signature*

Clear
Date

MonthDayYear
Date
Should be Empty:

EMPLOYEE AND VOLUNTEER RE-COMMITMENT FORM

Part 1: Changes to Contact Information (Address, Phone, or Email)

Part 2: Personal Status Changes

Part 3: Applicant's Re-Commitment Statement