Congregational or Employer Verification Form



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Congregational or Employer Verification Form


regarding child protection cackground checks for adult Youth leaders and chaperones attending Atlantic Coast Conference Bible Quizzing events. To be completed by congregational representative or employer only if original copies of background checks are maintained by congregational office or employer.

I verify that the following individuals, who are likely to attend ACC Bible Quizzing in 2015, have all undergone, within the past three years: 1) the Pennsylvania Child Abuse History Clearance Certification; 2) the Pennsylvania State Police Request for Criminal Record Check; and 3) the FBI Fingerprint Check (unless, in the case of a volunteer, the individual has lived in Pennsylvania for the past ten years and swears or affirms in writing that they have not been convicted of any crime, in another state, similar to the convictions disqualifying a person in Pennsylvania) and that these checks are valid through the for the duration of the Bible Quizzing season. Our congregation or organization maintains the results of all background checks in a confidential location.



Name(s) of Volunteer Leader or Chaperone Likely to Attend 2015 ACC Bible Quizzing:

1.

2.



3.

4.

5.



6.

Each of the above-named individuals has undergone, within the past three years: 1) the Pennsylvania Child Abuse History Clearance Certification; 2) the Pennsylvania State Police Request for Criminal Record Check; and 3) the FBI Fingerprint Check (unless, in the case of a volunteer, the individual has lived in Pennsylvania for the past ten years and swears or affirms in writing that they have not been convicted of any crime, in another state, similar to the convictions disqualifying a person in Pennsylvania) and these checks are valid through the for the duration of the Bible Quizzing season.

My congregation or organization has the results of background checks for each of the above individuals on file in a confidential location.

____ Yes ____ No ____ I’m not sure


Continued on reverse


Note: All paid and unpaid volunteer leaders or chaperones who attend an ACC Bible Quizzing event will be required to sign, at the beginning of that event, a “Volunteer Covenant” confirming that they:

  • Have never been charged with or convicted of child abuse or any criminal conduct relating to children,

  • Have undergone, within the past three years, the above-named background checks, and the results of their background checks are maintained by the church.

  • Understand what constitutes “child abuse” under Pennsylvania’s Child Protective Services Law.

  • Will not engage in any inappropriate or abusive conduct with children while attending this event.

  • Understand their duty as a mandated reporter of suspected child abuse under Pennsylvania’s Child Protective Services Law.

Name of Congregation/Employer __________________________________________________________

Name of Representative Completing this Form ___________________________________ (Please print)

Signature of Representative Completing this Form ____________________________________________

Title of Congregational Representative/Employer _____________________________________________

Date ____________

Please return this form to:

Atlantic Coast Conference

c/o Brook Musselman

2257 Old Philadelphia Pike

Lancaster, PA 17602

office@atlanticcoastconference.net

Please contact the ACC office with any questions:

office@atlanticcoastconference.net

717-394-8107



Atlantic Coast Conference Child Safety Policy: 1.29.15

Form B: Congregational Representative or Employer Verification


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