Balancing Acts

Appendices

• Draft Limited Access Agreement (check list format)
• Sample Screening Form
• Sample Agreement to Teach
• Code of Ethics

Draft Limited Access Agreement - Confidential

Introductory Paragraph in cases of allegation:

A serious complaint or allegation, now under review, has been made about you to the Sexual Misconduct and Abuse Response Team. While this complaint is being investigated, in order to protect the children and youth in our programs from potential risk, and in order to protect you from further suspicion, we ask you to abide by this interim agreement. Signing this document in no way constitutes a presumption or confession of guilt. This is a routine safety precaution, activated without prejudice toward particular individuals or circumstances. This document will be made known only to the Minister, the Religious Educator and the members of the Response Team (or other appropriate congregational entity). It will be kept in a locked file in the office.

Introductory Paragraph in cases of convicted sex offender:

The NAME OF CONGREGATION affirms the dignity and worth of all persons. We are committed to being a religious community open to those who are in need of worshipping with us, especially in times of serious personal troubles. However, based on your background, we have concerns about your contact with children and youth in our congregation. The following guidelines are designed to reduce the risk to both you and them of an incident or accusation. We welcome you to our congregation and our membership but your participation will be limited to ensure the safety of our children and youth and to assure that you will not be subject to future accusations.

Within these guidelines, the congregation welcomes your participation in adult worship services, coffee hour, committee meetings, adult education, all adult social events, and well supervised intergenerational events. You are to avoid all contact with children on congregation property or congregation-sponsored events. This includes the following:

Please do not talk with children.

Please do not volunteer or agree to lead, chaperone or participate in events for children and youth including such things as religious education classes, stories or talks for worship, youth group events, activities during intergenerational events, driving or otherwise transporting children and/or youth.

Please remain in the presence of an adult who knows your situation at all times when children are present.

If a child in the congregation approaches you, either at church or in a community place, politely and immediately excuse yourself from the situation.

Please avoid being in the building unsupervised when activities involving children are in session, such as nursery school or youth group.

I accept that the following people will be told of my circumstances in order for them to protect the children/young people for whom they care: INSERT NAMES AND/OR POSITIONS WITHIN THE CONGREGATION

I have reviewed this covenant and agree to abide by its provisions. I understand and agree that if I violate this agreement, I will be denied access to future church functions and church property.

I understand that this contract will be reviewed regularly every six months and will remain for an indefinite period.

______________________	___________
Signature	Date
______________________	___________
Witness	Date
______________________	___________
Minister	Date
______________________	___________
Director/Minister of Religious Education	Date
______________________	___________
Board Chair	Date

Check List Format

Introductory Paragraph in cases of allegation:

A serious complaint or allegation, now under review, has been made about you to the Sexual Misconduct and Abuse Response Team. While this complaint is being investigated, in order to protect the children and youth in our programs from potential risk, and in order to protect you from further suspicion, we ask you to abide by this interim agreement. Signing this document in no way constitutes a presumption or confession of guilt. This is a routine safety precaution, activated without prejudice toward particular individuals or circumstances. This document will be made known only to the Minister, the Religious Educator and the members of the Sexual Misconduct and Abuse Response Team. It will be kept in a locked file in the office

Introductory Paragraph in cases of convicted sex offender:

The NAME OF CONGREGATION affirms the dignity and worth of all persons. We are committed to being a religious community open to those who choose to worship with us, especially in times of serious personal troubles. However, based on your background, we have concerns about your contact with children and youth in our congregation. The following guidelines are designed to reduce the risk to both you and them of an incident or accusation. We welcome you to our congregation and our membership but your participation will be limited in ways to ensure the safety of our children and to assure that you will not be subject to future accusations.

You understand that you will not be allowed to volunteer or chaperone events for children and adolescents, including children’s religious education classes, talks with children/adolescents during worship, youth group, children’s and adolescents’ activities during intergenerational events, and driving children and young people.

The following activities checked "Yes" are activities that we feel are appropriate for your participation.

Worship services No ( ) Yes ( ) With support person* No ( ) Yes ( )

Coffee Hour: No ( ) Yes ( ) With support person* No ( ) Yes ( )

Adult meetings with children in building, such as choir: No ( ) Yes ( )

Adult meetings without children in building: No ( ) Yes ( )

Have a key to the building: No ( ) Yes ( )

Intergenerational church activities No ( ) Yes ( ) With support person* No ( ) Yes ( )

Intergenerational group outings such as ice skating, baseball games, etc:
No ( ) Yes ( ) With support person* No ( ) Yes ( )

Alone in building with minister or other staff: No ( ) Yes ( )

Access to church computer: No ( ) Yes ( )

Social activities in other member’s homes with children present:
No ( ) Yes ( ) With support person* No ( ) Yes ( )

Other:

__________________________________________: No ( ) Yes ( )

__________________________________________: No ( ) Yes ( )

__________________________________________: No ( ) Yes ( )

*A support person is a person who knows about your history/situation and has been designated by you with our approval to accompany you to activities where children and youth may be present.

I accept that the following people will be told of my circumstances in order for them to protect the children/young people for whom they care: INSERT NAMES AND/OR POSITION IN CONGREGATIONAL LEADERSHIP.

I have reviewed this covenant and agree to abide by its provisions. I agree that if I violate this agreement, I will be denied access to future church functions and church property.

I understand that this contract will be reviewed regularly every six months and will remain for an indefinite period.

______________________	___________
Signature	Date
______________________	___________
Witness	Date
______________________	___________
Minister	Date
______________________	___________
Director/Minister of Religious Education	Date
______________________	___________
Board Chair	Date

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:

________________________________________________________________________
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? ____ yes ____ no

If not, please tell us why.

A. Have you ever been convicted of any criminal offense? 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?

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?

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?

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?

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______________

Sample Agreement to Teach Form for Religious Educators and Youth Group Leaders

Name ____________________________________________________

Address _________________________________________________

__________________________________________________________

Phone _______________________

Cell Phone __________________

Email ________________________

I have read and understand our congregation’s policies on keeping children, youth and vulnerable adults safe. These include: [put in by name]

I agree to uphold these principles in my work with __________ [name of congregation] children, youth, adults, and families.

I have signed the Code of Ethics statement.

I affirm that I have never been accused of, convicted of, or pled guilty to any sexual crime. I also have not pled guilty to a lesser charge after having been charged with a sexual crime. I have never engaged in any form of child abuse, including sexual abuse. I have never been determined to have engaged in any sexual offenses in any civil, administrative, or ecclesiastical forum or other forum.

If there are any facts or circumstances in my background that call into question my being entrusted with the supervision, guidance, and care of children, youth, or vulnerable adults, I have met to review this information confidentially with the Minster and the Religious Educator.

Further, I agree to notify the Minster and the Religious Educator immediately should I be accused of sexual abuse, sexual offenses, sexual harassment, or other sexual improprieties in the time that I am working with children and youth in this congregation.

Signature______________________ Date______________

Code of Ethics for Adults and Older Youth Working with Children and Youth

Adults and older youth who are in leadership roles are in a position of stewardship and play a key role in fostering spiritual development of both individuals and the community. It is, therefore, especially important that those in leadership positions be well qualified to provide the special nurture, care, and support that will enable children and youth to develop a positive sense of self and a spirit of independence and responsibility.

The relationship between youth and their leaders must be one of mutual respect if positive potential is to be realized. There are no more important areas of growth than those of self-worth and the development of a healthy identity as a sexual being. Adults play a key role in assisting children and youth in these areas of growth. Wisdom dictates that children, youth, and adults suffer damaging effects when leaders become sexually involved with young persons in their care; therefore leaders will refrain from engaging in sexual, seductive, or erotic behavior with children and youth. Neither shall they sexually harass or engage in behavior with youth that constitutes verbal, emotional or physical abuse.

Leaders shall be informed of the code of ethics and agree to it before assuming their role. In cases of violation of this code, appropriate action will be taken.

I have read and understand the above statements of position, expectations, and actions.

Name Printed ______________________

Name Signed ______________________ Date______________

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Unitarian Universalist Association
25 Beacon St. | Boston, MA 02108 | 617-742-2100