Child and Youth Volunteer Annual Recommitment

Last Name
First Name
Cell Phone
Place of Employment
In the past year, are there pending, or have you been convicted of, or pled guilty or no contest to any criminal charges?

If you answer yes, please contact Miss at

Are you CPR certified?
Would you like to be CPR certified?
Is there any health related reason that would keep you from effectively working with or cause any potential harm to children?
If yes, please explain.

The information in this Recommitment Form is correct and complete to the best of my knowledge. I acknowledge that I have read the Child and Youth Protection Policy and have received a copy for my personal use. 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 or misrepresentation of information that I have provided may result in termination of employment or volunteer service with children/youth. Signing this form acknowledges that a background check may be run again at any time during my service to the church.

Date above box was checked