Safe Environment Facilitator Application

Safe Environment Facilitator Application

2 day training: Saturday, June 4, 2022 and Saturday, June 11, 2022.
Name *

First Name Last Name
Home Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Place of service within Archdiocese
Role/Job within Archdiocese
Cell Phone

Area Code Phone Number
Home Phone *

Area Code Phone Number
Email *
example@example.com
Name of Pastor, Principal, Administrator *
Parish/School/Program Name *
Parish/School/Program Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Parish/School/Program Phone

Area Code Phone Number
Parish/School/Program Email
example@example.com
Has any parish, school, facility, organization, or faith community ever terminated your employment of service?

Yes No
Why are you applying to be trained as a facilitator?
Are there any time restraints that effect your ability to facilitate a minimum of two sessions throughout the year?
Are you willing to travel to other parishes?
How many sessions are you willing to facilitate per year?
Are you fluent and willing to present the training in a language other than English? If yes, what language?
Please check: I understand the training takes place over two days and am willing and able to attend both days (Saturday, May28th and Saturday, June 4th). *

Yes No
Please upload copies of the following documents:

Browse Files

Cancel of
State Police Criminal Background Check

Child Abuse History Clearance

FBI Fingerprinting or Disclosure Form

Safe Environment Part 1 Certificate

Safe Environment Part 2 Certificate (Mandated Reporter Training)

Standards of Ministerial Behavior and Boundaries Acknowlegement Form

Information and Communication Technology Addendum Acknowledgement Form (if applicable)
I hereby affirm that my Pastor /Principal /Administrator has referred me for this volunteer position and approves of this application. *

I affirm this to be true. No.
I declare that all statements contained within this application are true and that any misrepresentation or ommission may be cause for rejection of my application, or dismissal from my involvement with the Archdiocese of Philadelphia Office for Child and Youth Protection's Safe Environment Program.

I agree to conduct training according to program guidlines and policies for the Protecting God's Children program, as customized for the Archdiocese of Philadelphia.

I understand that all materials are property of the Archdiocese of Philadelphia's Office for Child and Youth Protection and shall be returned upon the discontinuance of my service.

I understand that the Archdiocese of Philadelphia has a ZERO TOLERANCE policy for child abuse and takes all allegations of child abuse seriously. I further understand that the Archdiocse cooperates fully with the authorities to investigate all cases of alleged child abuse. Abuse of minors or vulnerable adults is grounds for immediate dismissal and possible criminal charges.

I understand the above and can withdraw from the application process at any time.
Please check: *

I understand the above statement and will comply with all guidelines and policies as set forth by the Archdiocese of Philadelphia Office for Child and Youth Protection.
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