Speaker Clearance Declaration Form – Non-Catholic Organization

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 a person who is the supervisor of the organization that the speaker represents or is employed and/or who is responsible for ensuring the safety of children and vulnerable adults in that organization.

SPEAKER INFORMATION:

Name(Required)

First Last

Date of Birth(Required)

Address(Required)

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

Employer/Affiliated Organization(Required)

CONFIRMATION OF TRAINING AND CLEARANCES:

I certify that the above listed individual has completed training and clearances intended to ensure the safety of youth and vulnerable adults as required by this organization.

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)

Please describe organizational requirements for individuals regarding protection of youth and vulnerable adults.(Required)

Signature(Required)

Today's Date(Required)

Printed Name(Required)

Organization(Required)

Email(Required)

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Speaker Clearance Declaration Form – Non-Catholic Organization