Chaperone Registration/Verification - Diocesan Form
St. Andrew Dinner - Monday, October 18, 2021, 6:30pm at Church of Our Lady of Lourdes, Utica
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Chaperone Information
Chaperones must be 21 or older, and attended Safe Environment training and passed a criminal background check within the last 5 years. If you have questions regarding your Safe Environment credentials, please contact the Office of Safe Environment at 315.470.1421 or safeenvrionment@syrdio.org.
Title *
First Name *
Middle Initial
Last Name *
Other last name(s) used
If applicable
Gender *
Date of Birth *
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Last four digits of Social Security Number *
Address *
City *
State *
Zip *
Primary phone number *
Email address *
Parish/School *
Medical Matters
If you have any special health or medically related needs that you feel the Office of Vocation Promotion Staff and your Parish leader should be made aware of, please explain below:
Specific Food Allergies *
Verification and Signature
I understand that as a chaperone/volunteer for the Diocese of Syracuse, I will adhere to the diocesan Child and Youth Protection Policy and Code of Conduct at all times. I understand that any action inconsistent with the diocesan policy, the Code of Conduct or failure to take action mandated by both documents may result in losing the privilege of working with children/youth/vulnerable adults in the Diocese of Syracuse.

I hereby give my consent to the Diocese of Syracuse to photograph, film, videotape and then use, reproduce, and publish said images of me for the purpose of event advertisement and promotion.
I have read the above and agree *
Electronic Signature *
In place of your signature, please type your full legal name.
Date *
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