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Statement of Compliance for Outside Organization 
Using Church Facilities  



Laurel Street Mennonite Church is committed to providing a safe environment for all children, youth and volunteers who participate in ministries and programs at our facilities.  Prior to completing this statement, you will be given a copy of our most recent Child Protection Policy to review.

  
The following questions must be answered in order to obtain consent for use of the church’s facilities.  



Have you received and read the Laurel Street Mennonite Church Child Protection Policy? 
 
Yes _____ No ____  


Does your group have a policy and procedures for practicing safe ministry? Yes___ No _____  

 
If yes, your group must provide to Laurel Street Mennonite Church a copy for review.  



Stipulations:  If your policy does not include a “two adult” rule; clearances and training for volunteers; procedures for immediate reporting of suspected child abuse to Childline; and a prohibition on being alone in the facility with a child not your own, you are expected to comply with these provisions as stated in Laurel Street Mennonite Church child protection policy.  
If you do not have a policy, your group is required to abide by the church’s written policy and procedures as would reasonably apply to your organization.


  
Briefly describe how you will implement this policy and procedures with your program. 

_________________________________________________________________________________  

_________________________________________________________________________________  

_________________________________________________________________________________  

_________________________________________________________________________________
  
_________________________________________________________________________________  



  
I have received and read the Child Protection Policy for Laurel Street Mennonite Church or provided evidence of our own policy.  Any questions that I have had have been answered to my satisfaction.  On behalf of my organization, I agree to observe and abide by the tenets of the policy/stipulations.
 
I certify that I am empowered to sign this document on behalf of my organization and agree that my organization does hereby indemnify, defend and hold harmless Laurel Street Mennonite Church from and against any and all claims arising out of my organization’s use of facilities.  


Name of Organization________________________________________________________   
Signature/Title             __________________________________   
Date           ______________________                

Church Office Use Only---  
 
The organization’s own policy has been reviewed and is acceptable. _____Yes ______No  

Comments:  
_________________________________________________________________________________
  
_________________________________________________________________________________
  
_________________________________________________________________________________
  
_________________________________________________________________________________
  
_________________________________________________________________________________


    
_________________________________________________________________________________ Signature/Title      Date