First Presbyterian Church of La Grange Children and Youth Protection Policy Renewal Application—Staff and VolunteersCLICK HERE TO REVIEW FIRST PRESBYTERIAN CHURCH OF LA GRANGE’S CHILDREN AND YOUTH PROTECTION POLICY AND PROCEDURES Name * First Name Last Name Email * Address * City, State, Zip * Age Range * Under 18 18-25 Over 25 In which children's/youth program(s), if any, are you currently involved? In what other children's/youth program(s), if any, do you plan to become involved? Have you at any time ever been arrested for any reason? * Yes No Have you at any time ever been convicted of, or pleaded no contest to, any crime? * Yes No Have you at any time ever engaged in, or been accused of, any child molestation, exploitation or abuse? * Yes No Are you aware of having any traits or tendencies that could pose any threat to children, youth or others? * Yes No Are you aware of any reason why you should not work with children, youth, or others? * Yes No If the answer to any of these questions is "Yes," please explain in detail: Applicant Verification and Release: I recognize that the organization to which this application is being submitted is relying on the information contained herein. Accordingly, I attest and affirm that all of the information that I have provided is absolutely true and correct. If I answered “yes” to any of the questions above regarding accusations or crimes, I am willing to provide records pertaining to these incidences when asked. I agree to abide by all policies and procedures of the organization, and to protect the health and safety of the children/youth at all times. * I agree. Signature * Please type your full name to electronically sign this document and agree to the Verification Statement above. Date * MM DD YYYY Thank you!
