Verification Of Compliance & Expectations

The following form must be filled out by the parish or diocesan Child Safety Coordinator. Please list all chaperones and young adult leaders that will be attending the Steubenville STL Mid-America conference with your parish or school and verify that they are in compliance with your home diocese safe environment requirements. This form must be submitted by June 13th. If any adults are added to your attendee list after the first submission, a second form must be filled out and submitted with the new additional names.

Group Name*

Group Leader Name*

First Last

Group Leader Email

Parish, School, or Diocesan Child Safety Coordinator*

First Last

Parish, School, or Diocesan Child Safety Coordinator Email*

Chaperones*

Enter the name of each chaperone and young adult in your group, one per line. If attending, the Group Leader's name must also be included. Seminarians, clergy and religious should also be included. If you need to add more names to a list you have already submitted, only provide the new name(s) for this form submission.

Child Safety Coordinator Affirmation*

I affirm that this form is being filled out and signed by the above listed Child Safety Coordinator and I do have the authority to sign off on the safe environment compliance of the individuals listed above.

Chaperones/Young Adults Compliance Affirmation*

I affirm that each of the chaperones & young adults listed on this form is in compliance with our home (arch) diocesan safe environment requirements and youth ministry policies.

Phone

This field is for validation purposes and should be left unchanged.