Sample Forms

Background Screening Program - Checklist

By implementing a screening program, you can significantly decrease the likelihood that misconduct will occur. It also will demonstrate that your school has acted with reasonable care to select appropriate workers.

DOWNLOAD: Sample Background Screening Checklist

Reference Response Information

It’s a good practice to ask for at least two independent references from all employee applicants, regardless of position, and from relevant volunteers. The best references come from places where the applicant has previously worked with students or children and youth. Make sure you call or have in-person meetings with the applicant’s most recent supervisor and at least two additional references, including those from ministries or other schools where the applicant has worked.  

Download: Sample Reference Response Information

Student Activity Participation Agreement

An activity participation agreement ensures that students and their families understand risks and helps protect your school from liability. Having parents fill out a consent form gives them the opportunity to provide their parental consent, their child’s emergency contact information, and information about any allergies or medical conditions.

Download: Sample Student Activity Participation Agreement

Notice of Injury and Suspect Neglect/Abuse Forms

It is important to complete reports such as Notice of Injury or Suspected Abuse as soon as possible after an incident. These forms help preserve the facts about the situation while they are still fresh. Recording physical symptoms immediately after identifying an injury or illness may help medical personnel determine treatment. Recording observations or allegations immediately after suspected or alleged neglect or abuse may help authorities better investigate the circumstances. The information on this form may also help you identify if your school should make any changes in activities, events, policies, or procedures.

Since these forms contain personal information protected by privacy laws, completed forms should always be kept in a secure place (e.g., a locked file cabinet, in a locked room used for confidential files, or a password-protected file).

DOWNLOAD: Sample Notice of Injury Form

DOWNLOAD: Sample Suspected Neglect or Abuse Form

Parent Consent - Student Photo Release

At various times during the school year, designated school staff or representatives, affiliated organizations, and the media may photograph or video school activities on and off campus. As a result, students' images and names could be captured either directly or indirectly. This sample form allows parents to give consent and helps schools craft their own policies about use of student images.

DOWNLOAD: Sample Parent Consent Student Photo Release

These are sample documents only. Your organization is responsible for compliance with all applicable laws. Accordingly, these documents should not be used or adopted by your organization without first being reviewed and approved by a licensed attorney in your area. Brotherhood Mutual assumes no liability in preparation and distribution of this sample documents.