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MOUNTAINVIEW CHILD SUPERVISION FORM Name: ________________________________ Phone/HP _____________________________ Sponsoring organization/business ____________________________________ The purpose of this form is to help ensure the safety and well-being of the children/youth of the Mountainview community. The questions below are of a personal nature. This information will remain confidential and will only be read by the school superintendent or another member of the Administration, if the superintendent is unavailable. The following passages remind us of God’s words regarding treatment of children. Please read each verse. 1. “Jesus said, ‘Let the children come to me. Don’t stop them! For the kingdom of Heaven belongs to such as these.’” (Matthew 19:14, Mark 10:14, Luke 18:16 NLB)
2. “Then he put the little child among them. Taking the child in his arms, he said to them, ‘Anyone who welcomes a little child like this on my behalf welcomes me, and anyone who welcomes me welcomes my Father who sent me.’” (Mark 9:36, 37 NLB)
3. “Don’t make your children angry by the way you treat them. Rather, bring them up with the discipline and instruction approved by the Lord.” (Ephesians 6:4 NLB)
4. “Fathers, don’t aggravate your children. If you do, they will become discouraged and quit trying.” (Colossians. 3:21 NLB)
5. “It would be better to be thrown into the sea with a large millstone tied around the neck than to face the punishment in store for harming one of these little ones.” (Luke 17:2 NLB)
6. “But if anyone causes one of these little ones who believe in me to sin, it would be better for him to have a large millstone hung around his neck and to be drowned in the depths of the sea.” (Matthew 18:6 NIV)
I have read each of the above verses. Signature:_________________________________ Describe the last two settings where you worked with children/youth. Date :__________ Place _____________________________________________ Your Duties _______________________________________________________ Date :__________ Place _____________________________________________ Your Duties _____________________________________________________ Age group of children with whom you have the most experience: NURSERY/TODDLER PRESCHOOL/K Ages 7-10 Ages 11-14 Ages 15-18
Please read the following “Definition of Abuse” as stated in Mountainview’s Child Abuse Policy. Child abuse includes physical abuse/neglect, sexual abuse (whether verbal, visual or physical), and emotional abuse. Abusers may be parents, teachers, school staff (expatriates or nationals), students, expatriate community members, or Indonesian community members. 1. Physical abuse is defined as any act which results in a non-accidental physical injury usually as the result of unreasonably severe corporal punishment, unjustified punishment, bizarre forms of punishment, extreme disregard for caution, or severe “mean-spiritedness.” 2. Neglect is defined as a long term failure to meet the basic needs of a child for food/nutrition, shelter, safety, nurturing, health care, schooling, and socialization. 3. Sexual Abuse
a. Verbal sexual abuse is defined as remarks (face-to-face or via phone, SMS, e-mail or letter) which include sexual threats, innuendoes, sexually explicit comments about a person’s body, solicitation, inappropriate sexual talking, obscenities, or any expression with intent to arouse or stimulate. b. Visual sexual abuse is defined as indecent exposure, showing or taking of suggestive pictures, peeping, leering, or staring at certain body parts. Visual sexual abuse also includes voyeurism, exhibitionism, showing of pornographic material, of genitals, pubic area, buttocks, or, if such person is a female, breasts, with the intent to arouse or gratify the sexual desire of either party. c. Physical sexual abuse is defined by fondling, sexual touching, masturbation in front of, or to the victim, rubbing, holding, and kissing for the purpose of sexual gratification. Further examples include oral, genital, anal, and breast stimulation; penetration by penis, fingers, or any other body part or object, of mouth, anus, or vagina; physical contact with a person’s clothed or unclothed genitals, pubic area, buttocks, or, if such person is a female, breast, with the intent to arouse or gratify the sexual desire of either party.
4. Emotional abuse includes chronic attitudes or acts that are likely to produce serious long-term emotional disorders. These may include chronic derogatory name calling, threats, blaming, sarcasm, belittling, criticism, constant yelling, and consistently using vocal tones, body language, and/or attitudes which demean a person.
In light of the above definition... Have you ever been formally accused of, arrested for, or indicted for physical, emotional or sexual abuse/harassment of a minor? YES NO Has there ever been an incident of physical, emotional, or sexual abuse or child neglect, as previously defined, when you were responsible for the child/children? YES NO If yes, please attach an explanation. Over the past year have you intentionally interacted with pornography? YES NO List the names and e-mail addresses or local phone numbers of references who would recommend you for working with children. One name should be of a pastor/elder. OPTIONAL SECTION. If you were abused as a child and want to make a statement about steps you have taken toward being able to maintain healthy relationships with children, you may do so here. You may want to briefly discuss counseling, healing, or restorative work in which you have participated.
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