Adapted from the Synod 2000 document “The Protection and Safety of Children and Young People”, and Approved on: 27/02/07

Every person related to MCRC working with young people under the age of 18 years, has to do the following before resuming his/her work:

• Read through this entire document
• Fill out and Sign the agreement form below

Please, print this signed Agreement Form, and hand it over to the Church Contact Person for Child Protection and Safety (Nadia Janse van Rensburg: 0420 982 935), to be filed in the church office for referral.


Date: xx/xx/20xx

Name & Surname:

Date of Birth:

Street Address:

Home Phone:

Mobile Number:

Email Address:

I hereby agree to abide by the rules and guidelines mentioned in the MCRC Child Protection and Safety Policy Procedures Manuel.


Full Name:






1.1 Introduction
1.2 Discipline of Children
1.3 Supervision of Children
1.4 Procedures for Reporting Unsafe Practices
1.5 Selection and Screening Procedures for Leaders
1.6 Confidentiality

2.1 Recognising Child Abuse
2.2 Procedures for Notification
2.3 Recording Allegations or Suspicion of Abuse

3.1 Crèche
3.2 Kingdom Kids Cell Groups
3.3 ROC Youth Cell Groups
3.4 Lighthouse Cell Groups
3.5 Holiday Club
3.6 Camping


APPENDIX A: Application Form to serve in Children’s/Youths Ministry
APPENDIX B: Check list for Reporting Disclosure
APPENDIX C: Personal Information Form for Excursion/Camp
APPENDIX D: Incident Report Form
APPENDIX E: Offsite from Church Programme Register



The Synod of the CRCA has been addressing the issue of `abuse’ over the last few Synods, and has published the document “For Justice and Healing”, to provide general and ministerial guidelines to church families and Sessions (Church Councils) on the nature and the effects of abuse.

Subsequently, it published the document “Healing a Broken Trust – Policy and Procedures in Responding to Complaints of Sexual Abuse and Harassment against Session Members and Church Workers in the Christian Reformed Churches of Australia” to give clear instruction on how to deal with allegations of sexual abuse.

Synod 2000 adopted as a “working” document, “The Protection and Safety of Children and Young People in the Christian Reformed Churches of Australia”. The intention of this was that each church should take this document and use it to formulate a document for their local church situation.

Classis Queensland requested that this third document be adapted into a form that is relevant for the situation in Queensland.

It provides guidance to Youth Club leaders, Youth Workers, Sunday School teachers, Cadet and GEMS (Calvinette) leaders, Holiday Club and Vacation Bible Camp leaders, Crèche volunteers, Religious Education Teachers, Cell Group Leaders and to all those who work in either a voluntary or paid capacity with children, to minimise the likelihood of accidents or abuse occurring.

It is very important for all those working with children and young people to be familiar with the contents of this document, and to follow all the guidelines given. Not only will this minimise the risk of accidents or abuse from occurring, it will also greatly reduce the likelihood of those working with youth/children being falsely accused of wrongdoing.


All human beings have been created in the image of God and have an inherent dignity given by God Himself. This implies that everyone and leaders in particular, have an obligation to ensure the safety of those entrusted to their care, and to treat them with respect. However, since the Fall (in the Garden of Eden), all aspects of human functioning have been affected by sin. Family and church relationships are also prone to sin and evil. We, therefore, cannot be naive and think that inappropriate conduct by leaders would not occur in the church context. Jesus strongly condemns those who offend against children who trust in Him and warns us that:
“…If anyone causes one of these little ones who believe in me to stumble [1][1], it would be better for him if a large millstone were hung around his neck and he were thrown into the sea.” (Mark 9:42, NKJ)

Yet, it is Jesus Himself who also brought deliverance from sin and evil, and by His Spirit provides the way to healing, reconciliation, hope and forgiveness.

The protection of children is not only a Biblical imperative but a national requirement and legislation in the various states and territories around Australia and has implications for all those involved in the nurturing, education, training and care of children and young people. For the Sessions in our churches the adoption of this document will ensure that those working in children’s and young people’s ministries will be provided with clear guidelines and good practices.

To the more mature leaders, and certainly to all head leaders, it is strongly recommended that “For Justice and Healing” also be read to provide understanding to the background issues.


In Mansfield Christian Reformed Church the following principles underpin child protection and safety and the development of individual church policies, practices and procedures:
• Children are made in God’s image and, as such, are entitled to a fundamental respect for their personhood.
• All adults have a God-given responsibility to care for children and to protect them from any kind of abuse, as well as to positively promote their welfare.
• Recognising a child’s vulnerability to harm, we, as God’s people, are to uphold the welfare of children and to protect them in all situations and environments to the best of our God-given ability.
• The value of the family is to be respected but not to the detriment of the well-being of the child at risk.
• The rights of families are also to be acknowledged and respected throughout the processes that arise from notification of child abuse.
• Church leaders, who have access to information regarding suspected or disclosed child abuse, must observe appropriate confidentiality in relation to the matter.
• All persons involved in the notification procedure must be treated with sensitivity, dignity and respect.
• Investigation of concerns about child abuse and neglect should not be undertaken by the leaders but referred to the Queensland Police Service (Police Child Abuse Unit), the Commission for Children and Young People (CCYP), and the Sexual Abuse Complaints Committee.



Mansfield Christian Reformed Church has committed itself to ensure that all children’s and youth activities should be a place where positive Christian values and a commitment to the safety of children and young people is evident and practised. While the Session (Church Council) is ultimately responsible to make sure that children are protected and safe from harm when they are with staff and volunteer leaders during the various church activities, each leader also has the responsibility to carry out the policies laid down in this document.

The foundational motivation for ensuring the safety of all participants should arise from the Biblical understanding of the preciousness of others, since they have been created in God’s image and so must be treated with dignity and respect.

The intent of this policy is to safeguard the welfare of all children and young people under the care and leadership of the church.

Children and young people have the right to feel safe in church related activities; there is no excuse for leaders working with children to abuse their position of trust. At the same time leaders, too, have a right to feel safe and to know that they are not going to be asked (or directed) to place themselves in vulnerable positions.

To ensure quality care, leaders working with children and young people are required to apply each section of this protocol whenever and wherever applicable.


In every aspect of life, organisations function best where there are clear guidelines and policies in place. Since Session (Church Council) has ultimate responsibility for all local church activities involving children and young people, it must take reasonable steps to ensure that the environment and the behaviour of leaders shall not place any child’s welfare at risk.

1.2.1. Appropriate Discipline of Children in the Care of Leaders

In the event that a child’s behaviour requires correction either for his/her own safety and well-being or that of the group members, it is important that the disciplinary action be appropriate to the occasion and not, in itself, perpetrating an abuse on the child.

The following standards are basic for good practice.

• Disciplinary action shall not be used without the permission of the parents and head leader.
• Physical force or restraint should not be used unless the child’s safety or the safety of another child is at risk.
• If isolation of a child is an option, the child must be within eyesight supervision of the/a group leader.

1.2.2. Code of Conduct for Young People

It is recommended that at the beginning of each year an agreed Code of Conduct and Discipline Strategies is drawn up by leaders and young people. For example:
As members of the Club/Fellowship we will:
• Respect our club leaders.
• Respect the views and feelings of others.
• Respect the right of every member to express his/her opinion.
• Respect the right of each member to be heard.
• Respect leaders’/members’ personal privacy and property.
• Show respect and extend common courtesy to visitors and guests.
• Show care and responsibility for equipment and property.
• Find the following behaviour unacceptable:
• smoking and alcohol within church/club building or during activities;
• violence;
• verbal abuse/harassment including ‘put downs’;
• substance abuse.

This Code of Conduct is to be visible at all times and reinforced during the year.

1.2.3. Code of Conduct for Leaders

As leaders of Children and Youth Ministries we will:
• Respect the dignity of others.
• Set an example in speech and action and model by Christian example at all times.
• Foster a positive relationship in which sensitivity and trust are maintained enabling others to view leaders as people in whom they can confide.
• Always have at least two adults present with any child / group of children, (unless in direct eyesight of another adult/leader).
• Avoid unaccompanied and unobserved activities with those in your care. Adopt the ‘in sight - out of hearing’ rule.
• Realise that bullying, physical, verbal or any other kind of abuse or neglect is unacceptable conduct by any leader in the church.
• Avoid potentially compromising situations e.g., shared accommodation with those in care.
• Recognise that age is a determinant of what is acceptable or unacceptable behaviour.
• Never engage in sexually provocative games.
• Discourage the use of inappropriate language.
• Inappropriate touching is unacceptable.
• Listen to allegations of abuse that a child makes and report/record the disclosure to the Minister or the designated Contact Person.
• Never do things of a personal nature for children that they can do for themselves, e.g., going to the toilet, dressing them.
• Never go into a toilet, bathroom or change room without another adult present.


Making arrangements for the proper supervision of children is one of the most effective ways of minimising opportunities for children and young people to suffer harm of any kind whilst in the care of church personnel.

The following standards of safe practice can apply equally to all children’s and youth ministries such as: Sunday School, GEMS (Calvinettes) and Cadets, Holiday Club, Youth Club, Crèche or Camp out activities, Cell Groups and apply equally away from or on church premises.

1.3.1. Planned Activities

• Excursions and visits should include preparation, planning and a program of the activities for the children and young people involved in the project.
• All excursions and visits must be entered into the church “Outing Register” prior to departure, with a clear description of which group is going, and where, and the entry must be initialled by the head leader of the group, an Elder or the Minister (This is important for Public Liability Insurance cover).
• Organisers should obtain, in writing, parental consent. This form gives the authority to the leader in charge to give consent for the child to receive any medical or surgical treatment that may be deemed necessary in the event of an emergency and the child’s parents cannot be located.
• Parents should be given full information about the trip, including details of the program of events and the activities in which the children and/or young people will be taking part and the type of transport to be used.
• Organisers/leaders are responsible for the welfare and the safety of the children/young people for the whole time that they are from home.
• Young people should not be left to their own devices in, for example, a town for the evening or shopping expeditions.
• All children should be adequately supervised and involved in suitable activities at all times.
• In circumstances when planned activities are disrupted, e.g., due to weather conditions, then organisers should have a number of alternative activities planned.
• No child/children should be left unattended after an activity is finished – Leaders should wait until ALL children have been picked up by parents/care-givers.

NOTE: Persons taking children/youth home in personal cars (eg Leaders) should have written or at least verbal permission from the parent / care-giver.

1.3.2. Adult/Child Ratios

The level of supervision must be adequate whether on church premises or on an excursion. When deciding how many adults are required to supervise, leaders must take into consideration a range of practical matters.
• The number of participants in the group.
• The nature of the site/venue.
• The activities to be undertaken.

For example, groups involved in abseiling or water activities will need to increase leader to children ratio in order to provide adequate supervision. Children from 0 - 12 years must be supervised at all times and a minimum ratio of one leader to 10 children both on and off church premises is advisable. There should be at least one leader of the same gender as the group.

1.3.3. General Supervision of Children

• Leaders in charge must be satisfied that helpers and adults who accompany group parties are fully competent and experienced to do so.
• Children must be supervised at all times and not left unsupervised at any venue whether it be indoors or out of doors.
• Leaders should know at all times where children are and what they are doing.
• Any activity using potentially dangerous equipment must have close and constant adult supervision.

1.3.4. First Aid

• If possible, at least one leader should have a First Aid Certificate and be acquainted with the location of the first aid box.
• The first aid box must be appropriately stocked and replenished. Any shortage is to be reported to the person appointed to care for First Aid supplies.
• Record all injuries in the Incident Report File, which is located in the First Aid Box. Fill in the form, giving as much detail as possible. The details of the person’s name, the time, date, injuries received, witness, and action taken must be recorded. The head leader must also be informed verbally.
• Serious accidents must also be reported verbally to the Minister or Chairman of Session (Church council).
• If there is no phone on the premises which are used for children’s / youth activities, a laminated sheet with emergency service phone numbers must be carried by the head leader along with a mobile phone.
• In the event of emergency at the church, the nearest phone is located in the Church Office.

1.3.5. Poisons

• All medicines, household, gardening and handyman products are to be kept out of reach of children and in safe and secure locations.
• A poisons information phone number is to be clearly displayed in the Church Office, along with other emergency service numbers.

1.3.6. Play and Playground Equipment

• All equipment must be regularly checked and any faults, which may cause injury, rectified.
• Toys used in crèches should have no small parts and should be washed regularly.

1.3.7. Audio/Visual Material

Leaders will note the ages of children and young people in their care and abide by the censorship standards provided.

1.3.8. Transport

• Overcrowding in private cars must be avoided (note: overcrowding may invalidate any insurance cover)
• Speed limits must be observed.
• Seat belts and proper child restraints must be provided.
• Leaders should make it their responsibility to determine, to the best of their ability, that the vehicle used is registered and roadworthy, and that the driver holds a current, valid licence and is a sound driver.
• All drivers for minibuses must have the appropriate license to carry passengers.
• Leaders should not take children alone in a car on journeys without parental permission, no matter how short the distance.
• If a child is to be transported by a person other than a recognised leader, that person should have been, wherever possible, known to a leader for a reasonable period of time.

1.3.9. Health

• Leaders are expected to refrain from smoking inside buildings, vehicles, tents and enclosures when caring for children.
• Sharing of cups/bottles should be strongly discouraged because of the risk of spreading infectious diseases, such as hepatitis A, glandular fever etc.
• Children who are HIV antibody positive by law do not have to disclose antibody status to the organisation. Regardless of the child’s status, he/she should receive the same love and care, although at times medical issues may need to be addressed.

1.3.10. Fire

A fire response and evacuation procedure will be formalised and displayed in each room. All children and leaders will be made aware of it.


• A “Church Maintenance Register” shall be kept in a designated accessible place, and any member of the church, and leaders in particular, who become aware of any item which requires maintenance shall make a dated, signed entry, outlining the maintenance needs. The person who completes the maintenance task shall date and initial the entry.
• Any person who has reasonable concern relating to unsafe practices should report the matter immediately to the head leader of their group. If, in the view of the person reporting, the head leader does not take appropriate action, he/she shall report the matter to the Session and Minister in the following manner:
o Notify the church Session regarding faulty equipment, facilities or structures, both verbally and in writing;
o Notify church Session regarding matters pertaining to unsafe leadership practices, verbally and in writing;
• Church Session will action matters expediently and maintain confidentiality and sensitivity as they address concerns.


1.5.1 Application/Screening Form

Before any person can serve as a volunteer or paid leader, or in any way work with children in any of the church’s ministries, including crèche, they shall be required to hold a “Blue Card” (i.e. a Suitability Notice for working with Children from the Commission for Children and Young People - CCYP) and fill out the Session approved application form (See Appendix A), and sign it in the presence of the Minister (or Chairman of Session).

This Form allows the intending leader to provide relevant details. The Form also has a declaration statement in which the leader is asked to disclose any previous criminal convictions or cases pending against him/her. The Form will also ask permission to carry out a police check if deemed necessary. Except as required by law, all details will be treated in confidence.

Although it is often felt to be an unnecessary burden, particularly if the person is already known to the Session, having good standards of practice in selecting people for church programs is to ensure the protection of children and young people from harm.

In Queensland, all volunteers and paid workers with children and young people are required to hold a “Blue Card” before working with children and youth!
Regardless of standing, all persons are to undergo the above procedures with the renewal of their “Blue Card.”

1.5.2. Defining the Leader’s Role

When a leader is appointed to a task, they shall be given a clear description or outline of what their role is, and who they are accountable to.

1.5.3. References

If the prospective leader or church worker is not well known by the Session, two references will be required from the previous church and/or from someone who can vouch for the applicant’s work experience with children.

1.5.4. Interview

At least two representatives appointed by Session or relevant committee will conduct an interview at which information contained in the application form can be further explored. This interview must also refer to this Child Protection Policy and ensure that the person has the ability and commitment required for the position.

1.5.5. Supervision

Any person appointed to a children’s/ youth ministry role shall have a mentor appointed to them for the first 6 months. This would usually be the head leader of the group. After successful completion of this time, yearly appraisals, overseen by Session or relevant committee, should be routine together with ongoing training.

1.5.9. Training

Leaders who work with children and young people are a valuable resource to the church. They shall be required to undertake appropriate training, which must include some basic Child Protection Awareness training.

Training, however, needs to be ongoing and not simply a once only provision.


All leaders must maintain appropriate confidentiality.

Confidentiality means to hold information in trust and to share it with others only in the interest of the person involved, with their permission, in order to seek consultation with another professional. Information may also be shared without violating confidentiality in order to protect others from harm. Confidentiality is not intended to protect abusers from being held accountable.

Confidentiality is not about “keeping secrets”. Secrecy is the absolute promise never under any circumstances to share any information that comes to you. A commitment to secrecy may also support maintaining the secret of child abuse.

Leaders (and parents) need to be aware that there are some situations in which confidentiality cannot be maintained (hence we use the term “appropriate” confidentiality.)

These are as follows:
• If you are concerned that a child or young person is in danger, either to themselves or to someone else;
• If you suspect that child abuse has occurred and an offence may have been committed.

This will mean informing the designated contact person for child protection in our congregation or, if unavailable, the Minister; and together with them informing a statutory protection agency, e.g., the Queensland Police Service [Police Child Abuse Unit], Commission for Children and Young People (CCYP).

Normally the parents of the child would also be informed unless the leader believes the parent(s) are the ones who have abused the child. (see 1.6.1)

1.6.1. Sensitivity

Informing parents of the child about whom you are concerned will need to be handled in a sensitive way and should only be undertaken in consultation with the designated contact person for the protection and safety of children in our church or the Minister.

Matters of sexual abuse should normally be left to either the Commission for Children and Young People or the Police Child Abuse Unit.

In dealing with a child protection agency, the welfare and safety of the child is the first consideration. Any notification that a leader may make, will remain confidential (although he/she may be subpoenaed).



Guidance should be taken from the indicators of child abuse and neglect from prior training conducted. In recognising the indicators of abuse and neglect, it is not necessary to prove that abuse or neglect has occurred or who is responsible for it.

A notification must be made on “reasonable grounds”. Reasonable grounds relate to the facts of concern and the nature and seriousness of the allegations, being mindful of the child’s age and circumstances.

There are various ways in which leaders may become aware of abuse, such as:
• a child discloses (tells you he/she has been physically or sexually abused);
• someone else tells you (another child, sibling, relative, friend of the family);
• observation of the child’s behaviour or knowledge of children generally leads to suspicion.

Whatever the case, leaders should respond in the following way:
• listen,
• believe,
• reassure,
• record,
• act,
• support.

It is not the responsibility of the church to investigate and collect evidence in suspected cases of child abuse or neglect. These are the responsibilities of CCYP and the Police.


2.2.1. If a Child Discloses – How Do You Respond?

There is no one set of rules to follow when responding to disclosure situations. However, the actions of leaders who are told of abuse should be guided by the following key points:
• stay calm – do not overreact;
• be a good listener;
• do not inquire into details of the abuse;
• do not interrogate the child;
• reassure the child that he/she has done the right thing by telling someone;
• do not promise to keep a secret;
• report to the designated contact person for child protection, or if unavailable, to the church minister;
• record in writing as soon as possible what was said.

Under no circumstance should any individual, or the church itself, attempt to deal with the problem of sexual or physical abuse alone.

2.2.2. If a Child Discloses – What Do You Do?

If a child discloses information about sexual or physical assault – it is the child’s protection and welfare that become your number one priority.

A child will rarely, if ever, disclose an abuse more than once. Do not push the child into telling you details of the sexual assault. Do not ask leading questions as this may lead to difficulties in having the evidence accepted in a court at a later date.
• If a child discloses sexual or physical abuse to a leader or any person within the church group, the police and CCYP should be informed at once. The police and CCYP officer should be left to investigate the claim.
• Ascertain whether the child is at risk or in danger – take action to ensure that the child is safe.
• In all cases the child’s parents (if not the perpetrator) must be notified, preferably in consultation with the statutory body and/ or the police.
• If there is any uncertainty that what the child has disclosed is abuse, if practical involve the designated contact person in your church.
• If the alleged abuser is a leader, then the designated contact person must be notified.
• The church minister and/or the designated contact person for child protection and safety should be contacted immediately. It is important that confidentiality be maintained, thus, if possible the person reporting the incident should be the one to speak to the statutory body, police and church minister about the matter.
• It is imperative that you do not contact the perpetrator without first consulting with the investigating police or the statutory body.


When an allegation of abuse has been made, the leader must record the details on the appropriate form (see Form 4.2 Appendix. B). The following is intended as a guide only.

Gain the following information (without interrogating the child):
• name and address and phone of the child you are concerned about;
• the nature of the alleged injury/abuse;
• your reason for suspecting that the child has been sexually or physically abused;
• date and time when the abuse occurred;
• any other information you consider relevant;
• has anyone been consulted – if so, who?

The above information is to be entrusted to the designated contact person who will be responsible for its safekeeping and may use it only to inform the Minister and the appropriate statutory body.


In addition to the general guidelines given above, the following specific procedures are to be followed by those involved in the following:

3.1 Crèche (if applicable)

All crèche personnel will meet with the crèche coordinator at least once per year (preferably quarterly) to familiarise themselves with crèche procedures, safety standards and conduct practices.

• Toilets doors are to be left unlocked and ajar when toileting children.
• Two carers must be rostered, one of which must be female.
• Children may only be taken from the crèche room for toileting purposes.
• Any significant medical problem should be reported to the parents immediately.
• First Aid qualifications are recommended.

(Also refer to Section 1 –Discipline and Supervision of Children)

3.2 Kingdom Kids Cell Groups

• At least one adult should serve in each class, doors to rooms are to be left open.
• Children may not leave the classroom except for illness, bathroom assistance or other compelling reasons.

(Also refer to Section 1 –Discipline and Supervision of Children)

3.3 ROC Youth Cell Groups

• Leaders shall not tolerate abusive behaviour between children in their programme.
• Each activity should be supervised by at least two adults.
• Any one-to-one meeting must take place in the open.
• If a child needs significant medical attention, the parents must be notified immediately.
• Activities away from the church facility, out of town, or overnight should be conducted in general compliance with camping and other aforementioned policies (see Section 1 – Discipline and Supervision of Children).
• Displays of affection should be limited to such actions as a brief hug, an arm around the shoulder, and open-hand pat on the back, a handclasp, or a light touch on the forearm. A child has the right to refuse any of these actions.
• First Aid qualifications are recommended.

3.4 Connect Cell Groups (and any other Youth Groups that may exist)

• Any one-to-one meeting should occur in the open.
• Displays of affection between youth leader and youth group member ought to be limited to such actions as a brief hug, arm around shoulder, pat on the back, hand clasp, or a light touch on the arm.
• No gifts, phone calls or letters of a suggestive nature should be directed to a youth group member by the group leader.
• Youth group leaders will not hold a youth group function without appropriate or sufficient supervision. These guidelines also apply to activities away from the church site.
• When transporting a youth group member alone in a vehicle, a parent or adult will be notified.

(Also refer to Section 1 –Discipline and Supervision of Children)

3.5 Holiday Club (if applicable)

• Leaders should not meet alone with a child behind closed doors.
• Leaders should not physically restrain a child in their care. Physical force or restraint should not be used unless it is believed to be the only means to prevent a child causing harm to self or another person.
• Children may not leave the room except for illness, toilet or other compelling reasons.
• All activities undertaken by participants must meet reasonable safety requirements.
• No leaders should enter a shower or toilet cubicle occupied by a child unless it is an emergency.
• Two members, male and female, should attend to any one child in terms of first aid, counselling, etc.
• Leaders, prior to commencement, must be informed of safety standards and conduct practices as outlined in ‘The Protection and Safety of Children and Young People in the Christian Reformed Churches of Australia’.

(Also refer to Section 1 –Discipline and Supervision of Children)

3.6 Camping

• Any one-to-one meeting should not be conducted behind closed doors.
• Individual female leaders will not enter male sleeping quarters / change rooms / toilets.
• Individual male leaders will not enter female sleeping quarters / change rooms / toilets.
• Discretion should be used when campers are dressing in dormitories, change rooms and toilets.
• Transportation of campers for any reason should not be one-to-one. Parental permission is required at all times for children under the age of 18 years of age.
• Emergency transportation must include two leaders of different gender if possible.

(Also refer to Section 1 –Discipline and Supervision of Children)


This is the person nominated by the church Session as the person suitable to receive complaints of physical or sexual abuse of a child, or the neglect or unsafe practices of a leader or church worker. This person will give advice and may act as a trusted support person to the victim and/or victim’s family.

Name & Surname:

Nadia Janse van Rensburg

After hours:
Mobile: 0420 982 935

The name of the Contact Person for Child Safety and Protection should be displayed in meeting venues used by children and young people.


APPENDIX A: Application to Serve in Children’s / Youth Ministry
APPENDIX B: Checklist for Reporting Disclosure
APPENDIX C: Personal Information Required for Excursion / Camp / Activity
APPENDIX D: Incident Report Form
APPENDIX E: Offsite from Church Program - Register


MCRC: Application to serve in Children’s/Youth Ministry.


Dear Prospective Volunteer,

As a church community we have an obligation before the Lord and the Laws of our country to do all in our power to provide a safe environment for children and young people who participate in our Children's /Youth ministries. In keeping with these obligations, and the Synod 2000 (Art 45.6) decision to adopt as a working document, "The Protection and Safety of Children and Young People" document, the Session (Church Council) requires every person, whether paid or a volunteer, to hold a “Blue Card” and complete this form. Once you have completed the form, you must have your signature witnessed by the Minister or and Elder of Session. If you have difficulty filling in this form, please seek the help of the Minister.

Please Note. Understanding that personal details are contained within this application, the information will be held only by the Minister/Youth Elder of the church.

Position you wish to serve in:

Do you hold a CURRENT “Blue Card”? No / YES

Registration Number:

Your Surname:

Christian Name(s):

Present Street Address:

Home Phone:

Mobile Phone:

Normal Occupation:

Date of Birth:

Marital Status:
Single / Engaged / Married / Separated / Divorced / Remarried / Widowed

1. Briefly outline why you would like to be involved in this position:

2. List any gifts, calling, training, education or other factors that you believe have prepared you to serve in this role:

3. Do you have any disabilities or conditions that might prevent you from performing certain types of activity relating to this position?
Yes / No

If yes, please explain:

4. Have you ever had a problem in the area of controlling your feelings or behaviour towards minors (people under the age of 18)?
Yes / No

If yes, please explain:

5. Have you ever been accused, charged or convicted of child abuse, or a crime involving actual or attempted sexual molestation of a minor?
Yes / No

If yes, please provide details:

6. Is there any other relevant information relating to child abuse or any other
matter pertaining to yourself, that the MCRC should know about in order to determine your suitability for the position?

7. Fill this in only if you have been a member of this church for less than 5 years!

List the name and address and phone number of the churches you were regularly attending in the previous 5 years (if any):

List all the previous church work and or non church involvement you had with children/youth work in the past 5 years (if any)

Church / Organisation ( ); Type of involvement ( ); Dates ( ); Contact Person ( ); Phone of Church / Organisation ( ).

8. Applicant's Statement:

The information contained in this application is true to the best of my knowledge. I authorise any persons, churches or organisations listed in this application to give the Minister (or other person designated by church council) of the Christian Reformed Church of Tivoli any information they may have regarding my character and fitness for children's /youth work

I also give consent for the Christian Reformed Church of Tivoli to obtain information about any criminal/traffic record pertaining to me that the police may hold. This includes records of pending charges. probationary orders, Section 699 Criminal Act, Spent Convictions Act, Section 26 CW A and all Children's Court appearances, and whether or not my name is recorded on the National Names Index as having a history in any other Australian state.

Should my application be accepted, I agree to perform my services on behalf of the Christian Reformed Church of Tivoli in a manner consistent with Biblical teaching, and any protocols issued to me from time to time. I undertake to immediately advise the Minister (or in his absence one of the Elders) of any change in the information provided by me in this application, or any other information, relevant to my suitability.

Applicant’s signature:

Print your full name:

Parent's/Guardian's Signature (if applicant is under 18 yrs of age):

Declared before me:

Name and Surname:


Street Address:



Signed (by the witness):

Thank you for completing this form.

Please return it to: The Minister,


(Allegations or Suspicion of Abuse)


Do not interrogate the child in order to obtain this information!

Full Name of Child:


Street Address:


Name of Leader/ Reporter:

Street Address:


Name of Church / Organisation / Group:

Disclosure Made (Reason for Reporting - record exactly what you were told):




Have parents been informed (if appropriate)?

Signed by Reporter:

Full Names:


Personal Information Required for Excursion / Camp / Activity

Full Name of Child:


Street Address:



Email Address:

Name of family Doctor:


Surgery Address:

Medicare Number:

Please indicate whether your child suffers from any of the following:
Diabetes / Asthma / Epilepsy / Heart condition / Bed wetting / Sleep walking / Travel

Allergies: Which symptoms occur during an allergic reaction?
Other – (give details):

Last tetanus immunisation received:

What regular medication does your child require?
Is there anything else the leader(s) should know about your child?

Consent to seek medical attention:

Where it is not practical to communicate with me, I authorise the leader in charge of the excursion / camp / activity to consent to my child receiving such medical or surgical attention as may be deemed necessary.

Parent / Guardian signature
Full Name:

Parent / Guardian signature


MCRC Incident Report Form

This form is to be completed after any form of incident and/or accident by leaders or staff attending to or present at such incidents/accidents.

This copy is to be handed in to the appointed First Aid person.
The original written in incident book that is with the First Aid Kit.

Full Name of Child:


Street Address:



Email Address:
Describe incident in your own words:
Injury sustained:

Cause of injury (child’s description of accident):
Action taken (treatment, referral to casualty, doctor, etc – give details):

Signature of Reporter:



Offsite from Church Program - Register

(To be left at Church Office or with contact parent for the program and has to be filed in church office Register after trip.




Date & Time of Departure from Church:

Date & Time of Return to Church:

Names of People Participating:


Full Name of Driver:

Licence number:

Vehicle description:

Vehicle registration number:

Signed off by Group Leader:

Full Name:


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