Group Verification Forms 2021

Transcription

1 Group Verification Forms 2021

2 Verification Forms The safety of the youth is our number one priority. The Steubenville Florida Conference Office works closely with each Diocese in Florida to ensure that all group leaders and chaperones attending the conference have completed the Safe Environment Requirements in accordance of the policies under the Charter for the Protection of Children and Young People. Each form below is specific to one of the seven (arch)dioceses in the state of Florida and one for out-of-state groups. Submit the proper form to your home diocesan contact. Diocesan Contacts Diocese of Orlando Signed and Sealed by your Parish Pastor Archdiocese of Miami Viviana Yerex Coordinator of Youth Ministry Phone: Diocese of Palm Beach Kathy Casey Diocese of Palm Beach Safe Environment Office Phone: Diocese of Pensacola/Tallahassee Jeanne M. Blake Office of Human Resource and Safe Environment Phone: Diocese of St. Augustine Norma Garcia Diocese of St. Augustine Youth and Young Adult Ministry Phone: ext Diocese of St. Petersburg Kim Sbarra Safe Environment Office Phone: ext Diocese of Venice Cara Smith Diocese of Venice Background Screening Coordinator Phone: Out of Florida Diocese Signed and Sealed by your home Diocesan Office (last form) 1

3 Diocese of Orlando Charter for the Protection of Children and Young People As Pastor of Church/Parish in the Diocese of Orlando, I hereby notify Catholic Servant Ministries, Inc that each adult listed below has been background checked and cleared in accordance with the policies of the Diocese under the Charter for the Protection of Children and Young People as set forth by the United States Conference of Catholic Bishops. I understand that no adult will be permitted to attend as a volunteer or participate that has not been cleared by their home diocese and is listed on this declaration Group Leader or Chaperone (Completed by Pastor ONLY) Number of Adults Verifying Signature of Pastor Date Verified and Signed (PARISH SEAL)

4 Archdiocese of Miami Charter for the Protection of Children and Young People As Archbishop/Vicar General/Chancellor of the Archdiocese of Miami, I hereby notify Catholic Servant Ministries, Inc that each adult listed below has been background checked and cleared in accordance with the policies of the Diocese under the Charter for the Protection of Children and Young People as set forth by the United States Conference of Catholic Bishops. I understand that no adult will be permitted to attend as a volunteer or participate that has not been cleared by their home diocese and is listed on this declaration Date of Fingerprinting (Completed by Archdiocesan Date of PGC (Completed by Archdiocesan Office ONLY) VIRTUS Report Submitted (Completed by Archdiocesan Number of Adults Verifying Signature of Archbishop/ Date Verified and Signed Vicar General/Chancellor

5 Diocese of Palm Beach Charter for the Protection of Children and Young People As Bishop/Vicar General/Chancellor/Vice Chancellor of the Diocese of Palm Beach, I hereby notify Catholic Servant Ministries, Inc that each adult listed below has been background checked and cleared in accordance with the policies of the Diocese under the Charter for the Protection of Children and Young People as set forth by the United States Conference of Catholic Bishops. I understand that no adult will be permitted to attend as a volunteer or participate that has not been cleared by their home diocese and is listed on this declaration Over the Age of 21 (Completed by Diocesan (Completed by Diocesan Office ONLY) Date of PGC (Completed by Diocesan Number of Adults Verifying Signature of Bishop/Vicar Date Verified and Signed General/Chancellor/Vice Chancellor

6 Diocese of Pensacola/Tallahassee Charter for the Protection of Children and Young People As Bishop/Vicar General/Chancellor of the Diocese of Pensacola/Tallahassee, I hereby notify Catholic Servant Ministries, Inc that each adult listed below has been background checked and cleared in accordance with the policies of the Diocese under the Charter for the Protection of Children and Young People as set forth by the United States Conference of Catholic Bishops. I understand that no adult will be permitted to attend as a volunteer or participate that has not been cleared by their home diocese and is listed on this declaration Group Leader or Chaperone (Completed by Diocesan Office ONLY) Date of PGC (Completed by Diocesan Number of Adults Verifying Signature of Bishop/ Date Verified and Signed Vicar General/Chancellor

7 Diocese of St. Augustine Charter for the Protection of Children and Young People As Bishop/Vicar General/Chancellor of the Diocese of St. Augustine, I hereby notify Catholic Servant Ministries, Inc that each adult listed below has been background checked and cleared in accordance with the policies of the Diocese under the Charter for the Protection of Children and Young People as set forth by the United States Conference of Catholic Bishops. I understand that no adult will be permitted to attend as a volunteer or participate that has not been cleared by their home diocese and is listed on this declaration Group Leader or Chaperone (Completed by Diocesan Office ONLY) Date of PGC (Completed by Diocesan Number of Adults Verifying Signature of Bishop/ Date Verified and Signed Vicar General/Chancellor Diocesan Seal

8 Diocese of St. Petersburg Adult Chaperone Verification Form As bishop of the Diocese of St. Petersburg ( Diocese ), the Safe Environment Office, on my behalf, has verified that each adult listed below has a current FBI Background Check and is cleared in accordance with the Diocese of St. Petersburg Policy for the Protection of Children and Vulnerable Adults and, the Florida Conference of Catholic Bishops, and the US Conference of Catholic Bishops Policy for the Protection of Children and Young People. No adult will be permitted to attend as a volunteer or participate on behalf of the Diocese who does not have a current FBI Background Check and has successfully completed Safe Environment Program training for adults who wish to have the care, responsibility, and or supervision of children and vulnerable adults. The individuals listed on this declaration are as follows: Parish/School Affiliation: Destination Address: Dates: Count Last Name First Name Social Security # (Last 4 digits) Position (Group Leader, Priest, Adult Chaperone) Number of Male Youth on Trip: Number of Female Youth on Trip: Number Verified: Bishop s Signature: Date:

9 Diocese of Venice Charter for the Protection of Children and Young People As Bishop/Vicar General/Chancellor of the Diocese of Venice, I hereby notify Catholic Servant Ministries, Inc that each adult listed below has been background checked and cleared in accordance with the policies of the Diocese under the Charter for the Protection of Children and Young People as set forth by the United States Conference of Catholic Bishops. I understand that no adult will be permitted to attend as a volunteer or participate that has not been cleared by their home diocese and is listed on this declaration Group Leader or Chaperone (Completed by Diocesan Office ONLY) Date of PGC (Completed by Diocesan Number of Adults Verifying Signature of Bishop/ Date Verified and Signed Vicar General/Chancellor

10 Steubenville Florida Adult Chaperone Verification Form Charter for the Protection of Children and Young People As (Arch)Bishop/Vicar General/Chancellor of the (Arch)Diocese I herby notify Catholic Servant Ministries, Inc and the Steubenville Florida Conference Office that each adult listed below has been background checked and cleared in accordance with the policies of the Diocese under the Charter for the Protection of Children and Young People as set forth by the United States Conference of Catholic Bishops. I understand that no adult will be permitted to attend as a volunteer or participate that has not been cleared by his or her home diocese and is listed on this declaration Group Leader or Chaperone (Completed by (Arch)Diocese ONLY) Number of Adults Verifying Signature of (Arch)Bishop/ Date Verified and Signed Vicar General/Chancellor (DIOCESE SEAL)