Chaperone Registration

Diocese of Ogdensburg Chaperone Registration Form

Chaperones must complete and submit the Diocesan Chaperone Registration Form. All Chaperones must be 21 years or older, VIRTUS trained and background checked. All Chaperone Registration forms will be reviewed by the Director of Save Environment. Please select the event you are chaperoning below.

Please select the Event you are Chaperoning:(*)

Youth Rally

Vocation and Youth Department Event

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Chaperone’s First Name:(*)

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Chaperone’s Last Name:(*)

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Gender:(*)

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Street Address:(*)

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City:(*)

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State:(*)

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Zip Code:(*)

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Date of Birth:(*)

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Cell Phone:(*)

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Home Phone:

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Email:(*)

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Emergency Contact First Name:(*)

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Emergency Contact Last Name:(*)

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Emergency Contact Cell Phone:(*)

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Emergency Contact Home Phone:(*)

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Parish:(*)

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Parish City:(*)

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T-shirt Size:(*)

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Are you First Aid/CPR certified? (*)

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Are you VIRTUS Trained?(*)

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Have you been background checked for work/volunteering with the Diocese of Ogdensburg? (*)

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Are you the owner of the vehicle that will be transporting minors to the event?(*)

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If you are not the owner of the vehicle, will you be driving at any time during this event?(*)

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Vehicle Information

Vehicle year/make/model:(*)

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License Plate #:(*)

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Vehicle Insurance

Do you carry a minimum auto liability limits of $100,000 per occurrence and $300,000 aggregate combined single limits of liability (or $100,000/$300,000 bodily injury; $50,000 property damage) and uninsured motorist coverage.(*)

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Insurance Company Name:(*)

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Policy #:(*)

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Expiration Date:(*)

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eSignature of Insured:(*)

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By eSigning my name above, I acknowledge that in the event of an accident while transporting children, vulnerable adult(s) or youth during an Diocese of Ogdensburg event, any claims will be tendered to my personal automobile insurance company, and my insurance is primary.

Vehicle Inspection

Is there a working seat belt for the driver and each passenger? (*)

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Do you enforce the wearing of seat belts by all passengers? (*)

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Are your vehicle's brakes, including the emergency brake, in good working order?(*)

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Does your vehicle's tires have a legal tread depth of at least 3/32”? (*)

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Are your brake lights, turn indicators and headlights in good working order? (*)

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Are your vehicle’s windows clear and provide an unobstructed view for the driver? (*)

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Does your vehicle have functioning rear view, center and left side mirrors? (*)

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Does your vehicle have any other physical defects that would interfere with the safety of the driver or passengers? (*)

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Please explain: (*)

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Does your vehicle have dual airbags? (*)

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What is the seating capacity of your vehicle? (*)

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eSignature of vehicle owner:(*)

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By eSigning my name above, I hereby affirm and certify that the information provided in the vehicle inspection section is true and accurate to the best of my knowledge.

License Information

Driver’s License #:(*)

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Exp. Date:(*)

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State Issued In:(*)

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Have you had any moving vehicle violations or at-fault accidents within the last three years?(*)

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If yes, please list:

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eSignature of Driver:(*)

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By eSigning my name above, I certify that the above information is true and accurate to the best of my knowledge. I will not seat any child under the age of twelve (12) or a small person in the front passenger seat. I hereby give my permission for a copy of my personal Driving Record Information (MV-15C) to be ordered and used in consideration of my transporting minors during the Diocesan event.

Code of Conduct for Adult Volunteers

By eSigning my name below, I promise to strictly follow the rules and guidelines in the Code of Conduct for Adult Volunteers as a condition of my providing services to the children, vulnerable adult(s) and/or youth of our diocese. I understand that as a volunteer working with children, vulnerable adult(s) and/or youth, I am required to attend VIRTUS training and to have a thorough background check including criminal history. I understand that any action inconsistent with this Code of Conduct for Adult Volunteers may result in my removal as a volunteer/chaperone with children, vulnerable adult(s) and/or youth.

As a volunteer, I will:
• Treat everyone with respect, professionalism, patience, integrity, courtesy, dignity and consideration, using positive reinforcement rather than criticism when working with children and/or youth.
• Consider a vulnerable adult(s) who habitually lacks the use of reason equivalent to a minor.
• Avoid situations where I am alone with children and/or youth at Church activities.
• Refuse to accept expensive and/or inappropriate gifts from children and/or youth or their parent/guardian without prior written approval from the pastor/administrator.
• Refrain from giving expensive and/or inappropriate gifts to children and/or youth without prior written approval from the parents/guardian and the pastor/administrator.
• Report suspected abuse to the vicar/pastor, administrator or appropriate supervisor.
• Cooperate fully in any investigation of abuse of children, vulnerable adult(s) and/or youth.
• Chaperones may not bring non-participating children on the trip/to the event.
As a volunteer, I will not:
• Smoke or use tobacco products in the presence of children, vulnerable adult(s) and/or youth.
• Use, possess, or be under the influence of alcohol at any time while volunteering.
• Use, possess, or be under the influence of illegal drugs at any time.
• Engage in sexual intimacies with the persons counseled. This includes consensual and nonconsensual contact, forced physical contact, sexting and inappropriate sexual comments.
• Use, possess, purchase or give pornographic material to a minor.
• Use physical force, humiliate, ridicule, threaten, or degrade children, vulnerable adult(s) and/or youth.
• Touch a child, vulnerable adult(s), and/or youth in a sexual or other inappropriate manner.
• Use any discipline that frightens or humiliates children, vulnerable adult(s), and/or youth.
• Use profanity in the presence of children, vulnerable adult(s) and/or youth.

eSignature of Chaperone:(*)

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Diocese of Ogdensburg

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