Speaker Clearance Declaration Form – Catholic - Roman Catholic Diocese of Greensburg

Speaker Clearance Declaration Form – Catholic

The Diocese of Greensburg is committed to ensuring that a safe environment is provided for all our youth and vulnerable adults. As part of that commitment speakers, presenters, and facilitators for any event in the Diocese must have completed appropriate training on the protection of minors and current and cleared background clearances.

Must be completed by an official of the Safe Environment Office of the home Diocese of the speaker.

SPEAKER INFORMATION:

Name(Required)

First Last

Date of Birth(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Home Diocese(Required)

Home Parish(Required)

CONFIRMATION OF TRAINING AND CLEARANCES:

I certify that the above listed individual has completed all necessary training and clearances as defined under the USCCB standards for protection of minors and is in good standing with the Diocese/Parish. Further, I certify that all clearances have been completed within the last five years.

Name of Training (VIRTUS or equivalent)(Required)

Date Completed(Required)

Name of Training (Mandatory Reporter Training or equivalent)(Required)

Date Completed(Required)

Name of Screening (Cleared Criminal Background Check)(Required)

Date Completed(Required)

Signature(Required)

Today's Date(Required)

Printed Name(Required)

Diocese(Required)

Email(Required)

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MINISTRIES

PARISHES

SCHOOLS

EVENT REGISTRATION

Speaker Clearance Declaration Form – Catholic