WPCw rD[ \@ׁ yō-{*L; X<<)?̦ T^UH*- v1M ^"l54Pnpcq Ԟ%'-Ԑ{@H$zsFvDS8<ҖAFBVhE-B=$8Tł:3LxIN;´ }l&<aW%yk 'Wn I3BM)MX/b{ Dvf춡hyN1V͟`E ]8T+S$ ^^UC0,0#ɾ(qm{|.& .!s4{/xW: U YtT-Iaq}6+] sȗ'cfېTvm&-@ICf"pmA){kfB=P|jz&Etb߽{0 (9 z!^-y+!BX#U}Ng % 0Y 0I 0 0 0 0 0 0 0 0 0 0 0 0 0 0l 0Q! 06" 0# 0# 0$ 0% 0& 0' 0( 0m) 0Q* 02+ 0, 0l- 0H/ 0\0U >2 0>2 03 04 06 0&;8UBa: B: D3: C: D+ ; 0<8; 0t; 0:; 03< 0B< 0< B*> D/> 0V.? 0@U.A 0tA B 4B D/QBU@B 0tB D/4C AcCU:D 1>D@ Do~D4ME^ aE@ mEo~wE BE D3F CEF@ _F 1eiF 7FolFHG 0tH 0(H AMH@ HolI@ mIo~wII 0tJ 0(/K ASWK@ K 1eK 7L 1U'L 7 |Lo~L 1UM 7 [M@ gMo~qM@ Mo~M@ wNo~N@ N@ Oo~OolO@ OolP B+sP DAP@ PolP@ UQo~_Q 1]Q 72:R@ lR@ vRo~R@ RolS@ tSol~SolS@ VTo`T@ U@ *Uo4U@ UolU@ jVoltV@ VoV@ WoWo~tX@ XolXhY mjY@ YoY 72pZ 0cZ D5[ D5:[ Awo[@ [o[ B\ D5\ B] D1]@ P] D5Z]@ ] D5] B*] D5] B*-^ D5W^@ ^ B7^@ ^ B7^ DA_ 0@O_ 01w_ 0.`w` 0.`4a 0.Ca 0.a 0.b 0.c 0.Dd 1e 72Sf 1f 72 g 1>g@ g 72g 1h 72h 1h 72Ai 1si 72i 1,j 72j 1j 72lk 1k 72%l 1Wl Cl 1el 7]m B*km D3m 72m 1m 72n 1n 72:o 1lo 72o 1%p 72pEp 04p 0Nq 1bq 72q 1r 72r 1r D3[s 72s 1s 72Gt 1yt 72u 12u 72uuu Cu Cv Cv C9v CSvMmv(qvNv Cv 1uv 72*w C\w Cvw CwAuto HP LaserJet 4 Plus - Local from Server on ESYNOD,,,,0(9 Z6Times New Roman RegularX(1&$& *%XXCEUS.,2S+P 0_level1  , ;1` hp x (#;23  ..  8.` hp x (#8  2P+P 0_level2  X 8.` hp x (#823  ..  8.` hp x (#8  2P+P 0_level3   8.444` hp x (#823  ..  8.` hp x (#8  2M+P 0_level4   5+` ` ` hp x (#523  ..  8.` hp x (#8  2M+P 0_level5   5+ hp x (#523  ..  8.` hp x (#8  2J+P 0_level6   2( hp x (#223  ..  8.` hp x (#8  2J+P 0_level7  4 2( hp x (#223  ..  8.` hp x (#8  2G+P 0_level8  ` /% hp x (#/23  ..  8.` hp x (#8  2G+P 0_level9   /%< <<hp x (#/23  ..  8.` hp x (#8  2SP 0_levsl1  , ;1` hp x (#;23  Ԁ  8.` hp x (#8  2PP 0_levsl2  X 8.` hp x (#823  Ԁ  8.` hp x (#8  2PP 0_levsl3   8.444` hp x (#823  Ԁ  8.` hp x (#8  2MP 0_levsl4   5+` ` ` hp x (#523  Ԁ  8.` hp x (#8  2MP 0_levsl5   5+ hp x (#523  Ԁ  8.` hp x (#8  2JP 0_levsl6   2( hp x (#223  Ԁ  8.` hp x (#8  2JP 0_levsl7  4 2( hp x (#223  Ԁ  8.` hp x (#8  2GP 0_levsl8  ` /% hp x (#/23  Ԁ  8.` hp x (#8  2GP 0_levsl9   /%< <<hp x (#/23  Ԁ  8.` hp x (#8  2SP 0_levnl1  , ;1` hp x (#;23   8.` hp x (#8  2PP 0_levnl2  X 8.` hp x (#823   8.` hp x (#8  2PP 0_levnl3   8.444` hp x (#823   8.` hp x (#8  2MP 0_levnl4   5+` ` ` hp x (#523   8.` hp x (#8  2MP 0_levnl5   5+ hp x (#523   8.` hp x (#8  2JP 0_levnl6   2( hp x (#223   8.` hp x (#8  2JP 0_levnl7  4 2( hp x (#223   8.` hp x (#8  2GP 0_levnl8  ` /% hp x (#/23   8.` hp x (#8  2GP 0_levnl9   /%< <<hp x (#/23   8.` hp x (#8  6 4Heading 1C92@p `GalleryC   ) Vp x (#)     8.` hp x (#8&&&S$\  `&Times New RomanS 6 4Heading 2 C92@p `GalleryC   ,      &&&S$\  `&Times New RomanS 6 z4Heading 3XXXW**jp`*Bookman Old StyleW       &&&S$\  `&Times New RomanS 6 4Heading 4OA* `"Comic Sans MSO  ) rcp x (#)     A7X` hp x (#A&&&S$\  `&Times New RomanS\  `&Times New Roman6 4Heading 5OA* `"Comic Sans MSO   ) rcp x (#)     A7X` hp x (#A&&&S$\  `&Times New RomanS 6i h4Heading 6   5+ r hp x (#5     A7X` hp x (#A&&& 6 4Heading 7OA* `"Comic Sans MSO   ) rcp x (#)     A7X` hp x (#A&&&S$\  `&Times New RomanS 6 4Heading 8xxxC92@p `GalleryC   ) Vp x (#)     8.` hp x (#8&&&S$\  `&Times New RomanS 6 4Heading 9   U=$`(Americana XBd BTU P 7,-(X7;1X` hp x ;    7.(X75+ ` hp x 5&&&S$\  `&Times New RomanS *jp`*Bookman Old Style d++++'dxdd'dxd<:Default Para0> .Footer  >4X` hp x >:8Page Number0> .Header  >4X` hp x ><:Footnote Ref. ,TitleC92@p `GalleryC 76(X7  &Vp x &7.(X7  5+ ` hp x 5&&&S$\  `&Times New RomanS &$ d d5)1dxd6 4Body TextW**jp`*Bookman Old StyleW 5+ ` hp x 55+ ` hp x 5S$\  `&Times New RomanS <ii :Body Text In   X 5+ ` hp x 5  5+ ` hp x 5&&&  2@p `Gallery(L23$ &!&9%XXCEUS.,  % %d;)2dxd$`(Americana XBd BT(L23$ &!&9%XXCEUS.,  ;)3dxd6&Draw Object <<=8C HKKKK* `"Comic Sans MShzCEIMQUY]aAutoList1""""""""i)1)a)D WPCfLH.513%)+-*yt.2 pQ/ H WPCfLH.513%)+-*  dIIII'dxdddO (35;AGMSY_11.1.1.1.1.1.1.1.M1.WPC%%513%)+- Level 1 Level 2 Level 3 Level 4 Level 5(L23$ &!&9%XXCEUS.,  ($PQR.A<< cU WPC%%513%)+-W WPCfLH.513%)+-* Level 1 Level 2 Level 3 Level 4 Level 5(L23$ &!&9%XXCEUS.,  ($XYQZJ-C<< ca (35;AGMSY_2a)a)a)a)a)a)a)a)]a)(359=AEIMQ3_WPCfLH.513%)+-*(359=AEIMQ4 b e WPCfLH.513%)+-*g WPCfLH.513%)+-*i WPCfLH.513%)+-*m l WPCfLH.513%)+-*WPC: g 513%)+-o WPC: g 513%)+-'Single1 dpppp5Single1dxds WPC: g 513%)+-u WPC513%)+-qf0$a359=AEIMQ5 " v  z WPC513%)+-qf| WPC; v 513%)+-~ WPC; v 513%)+-WPC: g 513%)+- WPC:  513%)+!eB eA A eA   WPC:  513%)+!eB eA A eA  WPCD k& 513%)+- WPCD k& 513%)+- WPC.513%)+!eB eA A eA  WPC.513%)+!eB eA A eA WPC513%)+-qf WPCC % 513%)+-U WPCMQ/3513 *%'513\O*3d%)+.-51dB"(;3$2#  0  .3  0  ;;;;)!dxdx)!dxdxQ6o&"D&raw Object Text <C HKKKK WPC:  513%)+!eB eA A eA  d)!dxdx d;;)! dxdx 5555)!dxdx )!dxdx&p d Pd)!dxdx&p Pd d)!dxdx 3+0 d d d 3+0 d d dIIII5 Shadow!dZdZ2c0Quick ""0 (O;$0  2#  a  .3  0` (#(#(b$0  0` (#(#2#   .3  0 ` (#` (#(xir$0  0` (#(#0 ` (#` (#2#(  0  )3  0 (# (#3|x($0  0` (#(#0 ` (#` (#0 (# (#2#(  a  )3  0h(#(#(F$0  0` (#(#0 ` (#` (#0 (# (#0h(#(#2#(   )3  0h(#h(#($0  0` (#(#0 ` (#` (#0 (# (#0h(#(#0h(#h(#2#  0  )3  0(#(#({$0  0` (#(#0 ` (#` (#0 (# (#0h(#(#0h(#h(#0(#(#2#  a  )3  0p(#(#(F$0  0` (#(#0 ` (#` (#0 (# (#0h(#(#0h(#h(#0(#(#0p(#(#2#     )3  0p(#p(# h,zCEIMQUY]aAutoList2""""""""i)1)a)"hE ` A ` PreviouschurchmembershipAI) dE ) A  Doyouhaveanyphysicalconditionsthatwouldpreventyoufromperformingcertaintypesofactivities 0 (liftingchildren,playingsports...)?Ifso,pleaseexplain.  AI) xdE{ xA |  Education/Employment/Skills  - HighSchoolAI)d` dEdr ` A0 ` 0 ` (#` (#0 (# (#0h(#(#College/UniversityAI) dEr AO h(#h(# OccupationAI)$` dE$! ` A0 ` 0 ` (#` (#0 (# (#0h(#(#EmployerAI)PdE! PAy "h(#h(# Hobbies/InterestsAI) XdE " XA "$ SkillsAI)xdExd$ A #A & Doyouhave0 ` &CPRtraining&FirstAidTraining&OtherAI)t` dEt& ` A0` (#` (#0 (#(#0x (# (#0 x(#x(#?>&") (# (# Trainingreceivedorcoursestakenthatwouldassistyouforministrywithchildrenoryouth '`$+ AI)xdE\* xA ]*&. AI) xdE+ xA߀ ;+'0   ,(1  ConvictionforaCriminalOffense   Answering yestothefollowingquestionwillnotnecessarilyprecludeyourinvolvementinvolunteer * ministry.Ameetingwillbearrangedwiththepastortodiscussthecircumstances. y Haveyoueverbeen# #؀convictedofacriminaloffenseforwhichapardonhasnotbeengranted?    &Yes0 ` 0 ` (#` (#&NoI  (# (#  VolunteerExperience   >  Descriptionofvolunteerexperience.Pleasegivedates. h  AI) xdE xA ]     `     h   AI) xdE xA  AI) xdEB xA C AI) xdE xA p  VolunteerMinistriesinWhichYouAreInterested !  Indicatetheareasinwhichyouwouldliketolead(L),assist(A)orreceivetraining(T) K _____0  SundaySchool(ages3through5)m(#(# _____0  SundaySchool(childreningrades1through6)@ (#(# _____0  ConfirmationMinistry(grades7andup)!(#(# _____0  ConfirmationMinistryRetreats/Events(grades7andup)j"(#(# _____0  ConfirmationMinistry_Mentoring_Ԁ(youthmovingfromgrade8andup)=#(#(# _____0  YouthAdvisor/Leader(grades7andup)$(#(# _____0  YouthRetreats/Events(grades7andup)_%(#(# _____0  Administration/OfficeHelp2&(#(# _____0  ProgramCoordinator '(#(# _____0  ParentingTips\!((#(# _____0  ChristianEducationCommitteeWork/")(#(# _____0  ArtsandCrafts#~*(#(# _____0  Drama/Puppets#Q +(#(# _____0  Music$$!,(#(# _____0  OtherAI) #dE & #A{%!-(#(# AI) xdE' xA 'p$0 AI) xdE) xA )!&3   ),&4  References   Pleaseprovidethenamesofthreeindividuals(notrelatives)whohaveknownyouforfiveyearsormore * andwhocanprovideareferenceforyou.Ifyouareundertheageof18,youmayusethenameofaparent y and/orteacher.Ifpossible,pleaseincludeatleastonereferencefromsomeoneat(Nameof L Congregation)EvangelicalLutheranChurch.Allpeoplelistedasreferencesshouldbeinformed  ofthatfact.USCE.,Referencesthatareacceptablearelimitedtothefollowing: v  (qxp"3"    3i:2q03  0 `   Formerorpresentpastor;CE.,US.,9USCE.,3i::݌I ` (#` (# Ќ  "3"    3p;2q03  0 `   Longtimefriend(minimumof5years);CE.,US.,;USCE.,3p;;݌ ` (#` (# Ќ   (qxx"3"    3=2q03  0 `   Oneparent(forminors);3=>=݌ k ` (#` (# Ќ   (rxx";"  ;`>0  2r03  0` (#(#  Teacher(forminors);;`>>݌ > ` (#` (# Ќ   (qxx"3"    3?2q03  0 `   (NameofCongregation)member(whohassufficientstrengthofrelationshiptocomment    ontheindividualspersonalhabitsandcharacter);3??݌h ` (#` (# Ќ   (qxx"3"    3A2q03  0 `   Employerorcolleague.CE.,US.,/<3AA݌; ` (#` (# Ќ  NameAI)dES A0  0` (#(#0 ` (#` (#0 (# (#0h(#(#0h(#h(#RelationshipAI)l dES l A0 (#(# AddressAI),dE, A0 ` 0 ` (#` (#0 (# (#0h(#(#0h(#h(#0(#(#0p(#(#0p(#p(#PhoneAI)dE AZ(#(# NameAI)dEr A0  0` (#(#0 ` (#` (#0 (# (#0h(#(#0h(#h(#RelationshipAI)l dEr l AO(#(# AddressAI),dE, A0 ` 0 ` (#` (#0 (# (#0h(#(#0h(#h(#0(#(#0p(#(#0p(#p(#PhoneAI)dE Ay(#(# NameAI)dE A0  0` (#(#0 ` (#` (#0 (# (#0h(#(#0h(#h(#RelationshipAI)l dE l An(#(# AddressAI),dE,7 A0 ` 0 ` (#` (#0 (# (#0h(#(#0h(#h(#0(#(#0p(#(#0p(#p(#PhoneAI)dE7 A(#(#  ApplicantsStatement  > IherebyacknowledgethattheinformationcontainedinthisVolunteerApplicationFormiscorrectto `  thebestofmyknowledge.Iauthorizeanypeoplelistedasreferencestoprovideanyinformationthey 3! mayhaveregardingmycharacterandfitnessforministry. " Iwillprovide(NameofCongregation)EvangelicalLutheranChurchwiththeresultsofapolice 0!$ recordscheckifoneisrequired. "% IagreetoadheretotheguidelinescontainedinSafeStepsofthe(NameofCongregation)Church #% ' CommunityasadoptedbytheCongregationalCouncilof(NameofCongregation)Evangelical |$ ( LutheranChurch. O%!) ApplicantsNameAI) d E g( A 'D$, ApplicantsSignatureAI)" dIE" * A0 0 (# (#0h(#(#0h(#h(#0(#(#0p(#(#DateAI) dIE* AA*&/p(#p(#    F&9(NameofCongregation)EvangelicalLutheranChurch#&9%| FO# ,6)2   -h*3 N %&9VolunteerInterviewForm#&9%O#XaX%&9   #&9%XXa"P#  F&9DocumentC#&9%| FP#   NOTE:AcompletedVolunteerApplicationForm(DocumentB)mustbeinhandpriortothe   interview.Iftheapplicanthasmarked yesinconnectionwithConvictionforaCriminalOffense,the X ] applicantshouldbereferredtothepastor. + 0 NameofApplicantAI) dE C A   1.Tellmeaboutyourexperiencewithvolunteerministryat(NameofCongregation)(joys,sorrows, "  insights,etc.).   AI) xdEh xA in  2.Tellmeaboutyourexperiencewithvolunteeringinothersettings(joys,sorrows,insights,etc.).  AI) xdE xA   3.Describeyourinterestinthevolunteerministry(_ies_)youhaveindicated. DI AI) xdE xA  4.Wouldyoubewillingtoattendatrainingsessionassociatedwiththatministry? ns  AI) xdE xA  # 5.Whenwouldyoubeavailableforthisvolunteerministry(daysandtimes)? "& AI) xdE% xA % ) 6.Whatistheminimumlengthofyourcommitment? &!, AI) xdE:) xA ;)@$/ 7.Whatisyourunderstandingofwhywerequiretrainingaboutabuse,aninterviewandreferences? *%2 AI) xdEd- xA e-j(5   p-u(6 8.DoyouhaveanyquestionsaboutanythinginSafeSteps?  AI) xdEs xA ty 9.Haveyouhadanypersonalexperiencewithabuse?Ifso,howwasithandled? % * AI) xdE xA    10.Ifyouhadreasontobelievethatachildoryouthwerebeingabused,whatwouldyoudo? O T  AI) xdE xA   11.Whatdoyouconsidertobeanappropriateshowofaffectionwithachild?...ayouth? y~  AI) xdE xA  12.Doyouhaveanyfurtherquestions?  AI) xdE xA ! AI) xdE xA  AI) xdE# xA $)# AI) xdE xA ' ̀SignatureofInterviewerAI) dE " A0  0h(#(#0h(#h(#0(#(#0p(#(#0p(#p(#DateAI)xdE" xA,"1+(#(#   XaX%&9#&9%XXa4^# F&9(NameofCongregation)EvangelicalLutheranChurch#&9%| Fz^# P+U&6   ,'7   %&9 VolunteerReferencesVerificationForm #&9%'_# F%&9  #&9% F_# F%&9 DocumentD #&9% F_#  NameofApplicantAI) dE A   ReferencecontactedAI)8 hdE8  hA0 0 (# (#0h(#(#0h(#h(#0(#(#0p(#(#0p(#p(#DateAI)tdE tAw |(#(# Methodofcontact&phone&letter&facetofaceconversation "  DetailAI)hdEb hA   AI)xdE; xA <A  ReferencecontactedAI)8 hdE8  hA0 0 (# (#0h(#(#0h(#h(#0(#(#0p(#(#0p(#p(#DateAI)tdE tA(#(# Methodofcontact&phone&letter&facetofaceconversation  DetailAI)hdE hA 9> AI)xdE xA  ReferencecontactedAI)8 hdE8  hA0 0 (# (#0h(#(#0h(#h(#0(#(#0p(#(#0p(#p(#DateAI)tdE tAch(#(# Methodofcontact&phone&letter&facetofaceconversation   DetailAI)hdEN hA  AI)xdE'! xA (!-" RecommendationAI)P dEP K$ A #& InterviewersSignatureAI), dE, & A0 0 (# (#0h(#(#0h(#h(#0(#(#0p(#(#DateAI)HdEH& A%&*!)p(#p(# XaX%&9  #&9%XXai# F&9(NameofCongregation)EvangelicalLutheranChurch#&9%| Fi# v+{&/   ,'0   %&9VolunteerReferenceVerificationScript#&9%j#    F%&9 DocumentE #&9% F0k#   (h/ (#(#(Churchreference  r w Hello,thisisnamefrom(NameofCongregation)   LutheranChurch,Midland.   Aswithmanychurchesandcommunityorganizations   today,wehaveascreeningprocessforallpersonswho di  volunteertoworkwithchildrenoryouth. 7<  Iamcallingyoubecauseapplicantindicatedinhis/her   applicationthathe/shetaughtSundaySchool/leda   youthgroup/helpedwithyourchildrensprogram...  Canyouverifythisinformation? ).  PersonalReference  r w Hello,thisisnamefrom(Nameof   Congregation)LutheranChurch,Midland.   Aswithmanychurchesandcommunity   organizationstoday,wehaveascreening di  processforallpersonswhovolunteertowork 7<  withchildrenoryouth.    Iamcallingyoubecauseapplicantlistedyou   asapersonalreference.  Howlonghaveyouknownhim/her? ).    (h/ (   AI) xdEt xA uz! Wouldyoupleasecommentonhis/herpersonalityandleadershipability? &+$ AI) xdE xA ' DoyouhaveanyreservationsaboutNamesworkingwithchildrenoryouth? PU*  AI) xdE xA  - Isthereanythingyouwouldcaretoadd? z"0 AI) xdE$ xA $3    ` Thankyouverymuchforyourhelp. &!6    F&9(NameofCongregation)EvangelicalLutheranChurch#&9%| Fs# +&<   ,'=   %&9VolunteerApprovalForm#&9%lt# F%&9    DocumentF   #&9% Ft#ApplicantsNameAI)E d2EE p A   &IntroductorySessiononSafeStepscompletedonAI)d d2Ed A߀(date). J O &VolunteerMinistryCovenant(DocumentA)signed.   &VolunteerApplicationForm(DocumentB)completedandsigned.   &VolunteerInterviewForm(DocumentC)completedandsigned. <A  &VolunteerReferencesVerificationForm(DocumentD)completedandsigned.  &Policerecordscheck(ifrequired)completedbyauthoritiesandreportreceivedfromapplicant.  NotesAI)dE A  AI) xdEy xA z AI) xdE* xA +0 AI) xdE xA  Theapplicantisapprovedtoserveinchildrensandyouthministriesat(NameofCongregation) 3!8# EvangelicalLutheranChurch. " $ PastorsSignatureAI) d2E % A0 0 (# (#0h(#(#0h(#h(#0(#(#0p(#(#DateAI)  d2E %  A$'p(#p(#    F&9(NameofCongregation)EvangelicalLutheranChurch#&9%| F{# +&0   -!(1 { &9ActivityPermissionForm  #&9%|# F&9DocumentG#&9%| F|#   /s%&9FortheyearSeptember1,AI) d8E  A0 0 (# (#toAugust31,AI),d8E, A0(#(#0p(#(#. p(#p(# NameofChildAI)T dET A0 ` 0 ` (#` (#0 (# (#0h(#(#0h(#h(#BirthDateAI)dE A0p(#(#0p(#p(#0 (#(#AgeAI).dE. A  (# (# AddressAI)gd8E  gA   PhoneAI)M` d8EM ` A0  0` (#(#0 ` (#` (#0 (# (#SchoolAI) d6E A0(#(#0(#(#0p(#(#0p(#p(#0 (#(#GradeAI)Wd6EW A  (# (# #&9%/sZ}#/s%&9Name(s)ofParent(s)orGuardian(s)AI)X d6EX  A   #&9%/s#/s%&9AlternatePersontoContactinEmergencyAI)ad6E aA  Relationshiptochild/youthAI) d6E  A0 0 (# (#0h(#(#0h(#h(#0(#(#0p(#(#0p(#p(#PhoneAI)wd6E wA(#(# AI) xd3EJ xA KP #&9%/sI#/s%&9AI) xd3EY xA Z_ #&9%/s#Igivepermissionforthechild/youthnamedabovetoparticipateinfieldtrips,retreats,campsandany " otheroffsiteactivitiesthataresponsoredby(NameofCongregation)EvangelicalLutheran # Churchandwhichareofferedaspartof(NameofCongregation)sSundayChurchSchool, $ ConfirmationMinistryprogram(including(NameofCongregation)s_Mentoring_Ԁprogram),(Nameof ]b% Congregation)YouthGroupactivitiesorotherministries. 0 5& OnoccasionswhenIcannotprovidetransportationmyself,Iconsenttomychildsbeingdriventoand !( fromtheseactivitiesbyanadult(NameofCongregation)member. ") Iunderstandthat(NameofCongregation)EvangelicalLutheranChurchwilldoitsbesttofollow O$T+ theguidelinessetoutinSafeStepsofthe(NameofCongregation)ChurchCommunitywhichis "%' , intendedforthehealth,safetyandprotectionof(NameofCongregation)schildren,youthandvolunteers. % - /s%&9ParentsorGuardiansSignatureAI) d8E ) A0  0h(#(#0h(#h(#0(#(#0p(#(#0p(#p(#DateAI)d8E) Ax)}$2(#(#   #&9%h/sۊ# F&9(NameofCongregation)EvangelicalLutheranChurch#&9%| Fw# (,-'6   Z-_(7 H   &9MedicalPermissionForm  #&9%:# F&9DocumentH#&9%| F#&9   #&9%#/s%&9FortheyearSeptember1,AI) d8E  A0 0 (# (#toAugust31,AI),d8E, A0(#(#0p(#(#. p(#p(# NameofChildAI)T dET[ A0 ` 0 ` (#` (#0 (# (#0h(#(#0h(#h(#BirthDateAI)dE[ A0p(#(#0p(#p(#0 (#(#AgeAI).dE.[ A  (# (# AddressAI)gd8E gA 3 8  PhoneAI)M` d8EM  ` A0  0` (#(#0 ` (#` (#0 (# (#SchoolAI) d6E  A0(#(#0(#(#0p(#(#0p(#p(#0 (#(#GradeAI)Wd6EW  A  (# (# #&9%/sR#/s%&9NameofFamilyDoctorAI)w d8Ew c A0 0 (# (#0h(#(#0h(#h(#0(#(#0p(#(#PhoneAI)cd8Ecc A p(#p(# ProvincialHealthInsuranceNumberAI)w ` d54Ew  ` A0  0h(#(#0h(#h(#0(#(#DateoflastTetanusshotAI)*d54E* A;@ (#(# #&9%/s#/s%&9Doesyourchildhaveanysevereorlifethreateningallergies?(eg.beestings,food,penicillinorotherdrugs,etc.)   YesAI)Xd8Ek XA0  NoAI); Xd8E; k XA0` (#(#0 ` (#` (#DetailAI)t d8Et k A (# (# #&9%/s.#/s%&9Doesyourchilduseorcarryanymedications?(eg.antibiotic,ventilator,_epi_Ԅpen,etc.) CH YesAI)Xd8E XA0  NoAI); Xd8E;  XA0` (#(#0 ` (#` (#DetailAI)t d8Et  A (# (# #&9%/s-#/s%&9Doesyourchildhaveanyphysical,emotional,cognitiveorbehaviouralconcernsorlimitations?  YesAI)XdE XA0  NoAI); Xd8E;  XA0` (#(#0 ` (#` (#DetailAI)t d8Et  AKP (# (# #&9%/s/#/s%&9Doesyourchildhaveanymedicalconditionsofwhichweshouldbeaware?  YesAI)XdE{ XA0  NoAI); Xd8E; { XA0` (#(#0 ` (#` (#DetailAI)t d8Et { A (# (# #&9%/s#/s%&9AI) xd3E xA " #&9%/s#/s%&9AI) xd3Ea xA bg% #&9%/s#/s%&9AI) xd3E xA  ( #&9%/s#/s%&9#&9%/s#Intheeventofaccident,sicknessorothermedicalemergency,Iherebyauthorize(NameofCongregation) ", EvangelicalLutheranChurchtosecuresuchmedicaltreatmentasisdeemednecessary.Itisunderstood #- thatmedicalcarewillbesecuredpromptlyandthatparentsorguardianswillbenotifiedattheearliest z$. possibleopportunity. M%R / Intheeventofaccident,sicknessorothermedicalemergency,(NameofCongregation)Evangelical &!1 LutheranChurch,itspastor,staffandvolunteersareherebyreleasedfromanyliability./s%&9 '"2 ParentsorGuardiansSignatureAI) d8E q* A0  0h(#(#0h(#h(#0(#(#0p(#(#0p(#p(#DateAI)d8Eq* A)$5(#(#   #&9%h/sr# F&9(NameofCongregation)EvangelicalLutheranChurch#&9%| F #/s&9 +&8 #&9%/s#  '-,(9  &9SuspectedChildAbuse  ReportForm#&9%#     F&9DocumentI#&9%| F#  f k Thisformistobecompletedbyapastor. k p DateAI)7` dl4E7 ` A   NameofChildAI)  dl4E V A   AddressAI)6dl4E6 A ]b  PhoneNumberAI)/ dl4E/  A   NameofPersonFilingReportAI) dl4E H A  NameofPersonReceivingReportAI)xdl4E xA OT NatureofSuspectedAbuse(physical,sexual,emotional,neglect)AI) dl4E A  AI) xdl4Em xA ns IndicationsofSuspectedAbuse(facts,physicalsigns,courseofevents...)AI)I dl4E I A $ AI) xdl4E xA  ActionTaken(includedateandtime)AI)dl4E A IN AI) xdl4E! xA !" Theaboveinformationwillserveasaguideandwillbenecessaryifareportisfiledwiththepoliceand/or s#x% theChildrensAidSociety.Allinformationiskeptstrictlyconfidential. F$K& SignatureofpersonreportingAI)x d Ex ^' A &!) PastorssignatureAI) d E ) A 8)=$, USCE., F%&9  (NameofCongregation)EvangelicalLutheranChurch#&9%| Fs# +&/ CE.,US.,_  ,'0  &9SuspectedChildAbuse  FollowUpReportForm#&9%S#     F&9DocumentJ#&9%| F#  f k Thisformistobecompletedbyapastor. k p NameofChildAI)  dl4E A   AddressAI)6dl4E6V A   PhoneNumberAI)/ dl4E/  A ]b  NameofPersonWhoFiledInitialReportAI)odl4E oA߀   NameofPersonReceivingReportAI)xdl4EH xA  ConclusionsAI)idl4Ei A OT AI) xdl4E xA  AI) xdl4Ex xA y~ AI) xdl4E) xA */ AI) xdl4E xA  AI) xdl4E xA   ActionTaken(includedateandtime)AI)dl4E A = B# AI) xdl4E" xA "& Theaboveinformationwillserveasaguideandwillbenecessaryifareportisfiledwiththepoliceand/or g$l) theChildrensAidSociety.Allinformationiskeptstrictlyconfidential. :%? * PastorssignatureAI) dIE %) A0 0 (# (#0h(#(#0h(#h(#0(#(#0p(#(#DateAI)K dIE%) K A(#.p(#p(#  F%&9  (NameofCongregation)EvangelicalLutheranChurch#&9%| FԶ# +&2   - (3  &9  MentorYouth  BoundariesForm#&9%#     F&9DocumentK#&9%| F,#XaX&9  f k   Thisformistobecompletedbyaparentorguardianinfamiliesparticipatingin(Nameof ~  Congregation)s_mentoring_Ԁprogram. d i  USCE., (NameofCongregation)sSafeStepsofthe(NameofCongregation)ChurchCommunity   offersthefollowinginconnectionwiththementoryouthrelationship:   "3"  32q03  0    Totheextentpossible,meetinsuchpublicenvironmentsasTimHortons,aparksetting,   (NameofCongregation)sFellowshipRoom,acommunity_centre_,etc.3݌ (#(# Ќ  "3"  32q03  0    Considermeetinginagroupwithoneormorefellowmentorsandyouth.3>݌(#(# Ќ  "3"  3 2q03  0    # #Alwaysobtainparentalpermissiontotransportyouthortobealonewiththem.3 :݌z(#(# Ќ  "3 "  342q03  0    Observetheguidelinesforproperdisplayofaffection.34a݌`e(#(# Ќ  "3 "  3!2q03  0    Whenindoubt,conferwiththepastor.CE.,US.,3!N݌FK(#(# Ќ  #&9%XXax#XaX%&9Ourfamilyiscomfortablehavingourchild...   (qxx "3"  3&2q03  0    meetwithhis/hermentoratthechurch3&S݌(#(# Ќ   (qxx"3"  32q03  0    meetwithhis/hermentorinapublicvenue(park,_McDonalds_,Tim_Hortons_,etc.)3݌(#(# Ќ   (rxx"3"  3K2r03  0    visitourchildspublic/schoolactivities(hockeygame,dancecompetition,etc.)3Kx݌\a(#(# Ќ   (qxx"3"  32q03  0    meetwithhis/hermentorinourfamilyhome3݌( -(#(# Ќ   (qxx"3"  3:2q03  0    meetwithhis/hermentorinthementorshome3:g݌!(#(# Ќ  Iunderstandthatthisdirectioncanberevisedinthecourseofthe_mentoring_Ԁrelationship. $! #&9%XXaB#/s%&9ChildsNameAI)CdIEC' A 2'7"$ ParentsorGuardiansSignatureAI) d8E ) A0  0h(#(#0h(#h(#0(#(#0p(#(#0p(#p(#DateAI)d8E) A6);$'(#(# #&9%h/s# F&9  (NameofCongregation)EvangelicalLutheranChurch#&9%| F# +&+   -(,   Notes  c  c"0    USCE.,TheseModelFormsforaCongregationalScreeningpolicy_were_Ԁmostrecentlyrevisedbythe  EasternSynodCouncilinMarch2003.CE.,US.,