Group Verification Forms 2021

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Group Verification Forms

2021

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1 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: 305-762-1185

Email: [email protected]

Diocese of Palm Beach Kathy Casey

Diocese of Palm Beach Safe Environment Office

Phone: 561-775-9530

Diocese of Pensacola/Tallahassee Jeanne M. Blake

Office of Human Resource and Safe Environment

Phone: 850-435-3570

Diocese of St. Augustine Norma Garcia

Diocese of St. Augustine Youth and Young Adult Ministry

Phone: 904-262-3200 ext. 108 Email: [email protected]

Diocese of St. Petersburg Kim Sbarra

Safe Environment Office Phone: 727-344-1611 ext. 5303 Email: [email protected]

Diocese of Venice Cara Smith

Diocese of Venice Background Screening Coordinator

Phone: 941-441-1104

Out of Florida Diocese

Signed and Sealed by your home Diocesan Office

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Adult Chaperone Verification Form Charter for the Protection of Children and Young People Steubenville Florida High School Youth Conference July 16 – 18, 2021

Group Leader and Adult Chaperone

Verification Form for the

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.

Parish/Group Name:

# Full Legal Name

(Must Match Online Registration)

Group Leader or Chaperone

Date of Fingerprinting

(Completed by Pastor ONLY)

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 20. _________________________ _______________________ ______________________ Number of Adults Verifying Signature of Pastor Date Verified and Signed

(PARISH SEAL)

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Adult Chaperone Verification Form Charter for the Protection of Children and Young People

Verification Form for the

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.

# _{Full Legal Name}

Date of Fingerprinting (Completed by Archdiocesan Office ONLY) Date of PGC (Completed by Archdiocesan Office ONLY) VIRTUS Report Submitted (Completed by Archdiocesan Office ONLY) 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 20. _________________________ _______________________ ______________________ Number of Adults Verifying Signature of Archbishop/ Date Verified and Signed

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Group Leader and Adult Chaperone

Verification Form for the

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.

# Full Legal Name

Over the Age of 21

(Completed by Diocesan Office ONLY)

(Completed by Diocesan Office ONLY) Date of PGC (Completed by Diocesan Office ONLY) 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 20. _________________________ _______________________ ______________________ Number of Adults Verifying Signature of Bishop/Vicar Date Verified and Signed

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Verification Form for the

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.

# Full Legal Name

(Completed by Diocesan Office ONLY) Date of PGC (Completed by Diocesan Office ONLY) 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 20. _________________________ _______________________ ______________________ Number of Adults Verifying Signature of Bishop/ Date Verified and Signed

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Group Leader and Adult Chaperone

Verification Form for the

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.

# Full Legal Name

(Must Match Online Registration) Group Leader _{or Chaperone} Date of Fingerprinting(Completed by Diocesan Office ONLY) Date of PGC (Completed by Diocesan Office ONLY) 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 20. _________________________ _______________________ ______________________ Number of Adults Verifying Signature of Bishop/ Date Verified and Signed

Vicar General/Chancellor Diocesan Seal

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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)} (Group Leader, Priest, Position Adult Chaperone) 1 2 3 4 5 6 7 8 9 10

Number of Male Youth on Trip: Number of Female Youth on Trip:

Number Verified: Bishop’s Signature:

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Group Leader and Adult Chaperone

Verification Form for the

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. Parish/Group Name:

# Full Legal Name

(Must Match Online Registration) Group Leader _{or Chaperone} Date of Fingerprinting(Completed by Diocesan Office ONLY) Date of PGC (Completed by Diocesan Office ONLY) 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 20. _________________________ _______________________ ______________________ Number of Adults Verifying Signature of Bishop/ Date Verified and Signed

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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.

# Full Legal Name

(Completed by (Arch)Diocese ONLY)

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 20. _________________________ ________________________ ______________________ Number of Adults Verifying Signature of (Arch)Bishop/ Date Verified and Signed

Vicar General/Chancellor

(DIOCESE SEAL)