• St. Dysmas Worship Service Visitor Form

    ***Please read, complete, and submit this page with your access forms***

  • A maximum of 10 visitors are allowed to worship with St. Dysmas each Tuesday evening within the walls of MDSP in Springfield. Visitors must be 18 years of age. Visitors are considered volunteers and are REQUIRED to complete:

    1. St Dysmas Worship Service Visitor Form
    2. Please completely read and sign the Guidelines for Worship form
    3. DOC-Background Check Authorization
    4. A DOC-Release and Waiver of Liability form
    5. MDSP Chapel Visit Request Form
    6. DOC-Consent to Search Authorization and Registration forms
    7. DOC-On-Line Videos Form

    Each form must be filled out COMPLETELY (Yes, we MUST have your social security number!) and CORRECTLY or you will not be approved to join worship.

    Completed forms must be completed 2 weeks prior to the scheduled visit date.

    Please contact the St. Dysmas office for more information.

    Your visit to worship with St. Dysmas Congregation is important to the men and they greatly appreciate your attendance!

  • Date of intended visit
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Preferred contact

  • Questions? Call the St. Dysmas office at (605) 338-1735 or email visit@stdysmas.com

    Pr Jeff Backer's cell phone at (605) 360-3409, Pr Laura Phillip's cell phone at (605) 359-6294

  • Guidelines for Worship

    St. Dysmas Lutheran Church
    Mike Durtee State Prison (MDSP)
    1412 Wood Street, Springfield, SD 57062
    St. Dysmas Office: 605-338-1735

  • PLEASE MEET AT GILL HALL BY 6:30 PM WITH YOUR DRIVERS LICENSE OR GOVERNMENT ISSUED PICTURE ID.


    The name on your DOC Access form must appear exactly as it does on your driver's license

    • Your visit to a St. Dysmas worship is important to the men. They greatly appreciate your presence and attendance! Your involvement is a way for the men to maintain contact with the outside world, worship with fellow sisters and brothers in Christ, and to know they have not been forgotten. Your time with the men of St Dysmas relates to what our Lord speaks of in Matthew 25 and Hebrews 13; to visit those in prison.

    • VISITORS ARE SUBJECT TO ALL POLICIES AND RULES AS IDENTIFIED IN THE VOLUNTEER HANDBOOK.

    • DRESS CODE for prison visitation is conservative.

      Clothing NOT ALLOWED: Hats or any headwear (including bandanas), hooded sweatshirts, open toed shoes, flip flops, tops of the following nature - tank, spaghetti strap, midriff, tube, shoulder-less, back-less,
      halter, or low cut. NO SHORTS, stretch or yoga pants, tight jeans, dresses/skirts shorter than knee high. Low-rise pants which allow skin or undergarments to be seen may be deemed inappropriate by staff.

    • Pockets must be emptied of all items (keys, wallets, pens, knives, cell phones, candy/cough drops/gum).

    • Any medications you MUST have with you must be pre-approved.

    • Items NOT ALLOWED to be taken into prison: No gum, food, cameras, purses, coats, pocket-knives, tobacco products, smart watches, Fit-Bit's, cell phones, beepers, or any other type of wireless or electronic devices (even if
      turned off or set to vibrate). They should be left in your car or stored in a locker at the checkpoint.

    • Screening and/or pat-down searches are required for all visitors.

    • Please be quiet at the entrance checkpoint (main gate into the prison). Follow the directions of the officer.

    • Visitors should sit among the men in small groups of two to three people. A handshake is the only allowed physical contact between a visitor and an offender.

    • DO NOT ask inmates why they are incarcerated, how long they have been incarcerated; ask for, or accept an offender's mailing address, offer help or promise favors.

    • DO NOT give out your personal information such as your full name, address or phone numbers to inmates. There are proper channels for offenders and families if they need help.

    • A restroom is available inside the entrance checkpoint. A restroom is not available once you are inside the secure area, so please be sure you are set before entering the prison.

    • If you are sick or not feeling well, please do not attend

    • For those with limited mobility, please notify us of your needs. We will try to accommodate your needs to attend worship.

    • Questions? Call the St. Dysmas office at (605) 338-1735, Pastor Jeff Backer's cell phone at (605) 360-3409, or Pastor Laura Phillip's cell phone at (6050359-6294.
  • Date
     - -
    2 digit month, 2 digit day, 4 digit year

  • BACKGROUND CHECK AUTHORIZATION

  • CHECK ONE:
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Date of Birth
     - -
    2 digit month, 2 digit day, 4 digit year
  • I hereby authorize the South Dakota Department of Corrections, or its designated agents and representatives, to obtain and review my criminal background. I certify that the information given by me is true, complete, and correct, to the best of my knowledge and belief and made in good faith. The DOC and its designated agents or representatives shall maintain all information received from this authorization in a confidential manner in order to protect my personal information, including, but not limited to, addresses, social security numbers, and dates of birth.
  • Date
     - -
    2 digit month, 2 digit day, 4 digit year

  • SECURITY QUESTIONNAIRE

  • Please answer the following questions to the best of your knowledge. If you have any questions or you are unclear about a question, please discuss it in the interview.
  • 1. Have you ever been convicted of a felony or misdemeanor?
  • 2. Have you ever heen convicted of any misdemeanor crime related to domestic violence?
  • 3. Have you been charged with a felony or misdemeanor in which a conviction determination is pending?
  • 4. Have you ever been convicted of DUI, DWI, or a related offense?
  • 5. Have you ever engaged in any sexual abuse in a prison, jail, lockup, community confinement facility, juvenile facility, or other institution?
  • 6. Have you ever been convicted of engaging or attempting to engage in sexual activity in the community facilitated by force, overt or implied threats of force, or coercion, or if the victim did not consent or was unable to consent or refuse?
  • 7. Have you ever been civilly or administratively adjudicated to have engaged in the activities described in the previous question?
  • 8. Do you know anyone incarcerated in a correctional facility?
  • 9. Do you know anyone who has ever been incarcerated in a correctional facility? This includes anyone who is or has been on parole.
  • 10. Have you ever served as a sponsor for an offender?
  • 11. Do you know anyone who works for the South Dakota Department of Corrections (SDDOC), or has ever worked for the SDDOC?
  • 12. Do you use illegal drugs of any type?
  • 13. Have you ever been terminated for cause from any job?
  • 14. Have you ever been in the United States military service?
  • 15. If so, have you ever been discharged from the United States military service under less than honorable conditions?
  • I certify that the information I have provided is true, correct, and complete to the best of my knowledge and belief. I understand that misrepresentation, falsification, or omission of facts called for in this questionnaire is cause for cancellation of my application.
  • Date
     - -
    2 digit month, 2 digit day, 4 digit year

  • DOC RELEASE AND WAIVER OF LIABILITY

  • By my signature below, I acknowledge that I am aware of, appreciate the character of, and voluntarily assume the risks associated with being on DOC properly, or participating in DOC activities within the following facilities:

    South Dakota State Penitentiary, Jameson Prison, Sioux Falls Minimum Center, Mike Durfee State Prison, Yankton Minimum Center, Rapid City Correctional Facility, Rapid City Minimum Center, South Dakota Women's Prison, or Pierre Minimum Center.

    I understand that risks associated with such entry and/or participation in DOC activities include, but are not limited to, bodily injury, property loss or damage and death.

    By my signature below, on behalf of myself, my heirs, next of kin, successors in interest, assigns, personal representatives, and agents, I hereby:

    1. Waive any claim or cause of action against and release from liability the State of South Dakota, its officers, employees, and agents for any liability for injuries to my person or property resulting from such entry and/or participation in DOC activities.
    2. Agree to indemnify and hold harmless the State of South Dakota, its officers,
      employees, and agents for any claims, causes of action, demands, expenses, judgments, fees and costs of whatever kind or character arising from, by reason of, or in connection with my entry to a DOC facility or participation in DOC activities.

    I have carefully read this RELEASE AND INDEMNITY AGREEMENT, or had it read to me in a language I fully understand, and I understand all of the terms. I understand I have given up substantial rights by signing this agreement and that it is the intention of the parties that the State and its officers, agents and employees shall not be liable or in any way responsible for injury, damage, liability, loss, or expense resulting to me due to accidents, mishaps, misconduct, negligence, or injuries. My signature below has been made freely and voluntarily without any inducement, assurance or guarantee being made.

  • Date of Birth
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date:
     - -
    2 digit month, 2 digit day, 4 digit year

  • MDSP Chapel Visit Request Form

  • Date:
     - -
    2 digit month, 2 digit day, 4 digit year

  • CONSENT TO SEARCH AUTHORIZATION AND REGISTRATION - VISITORS

  • A DOC Facility is: A place, institution, or building (or part thereof), set of buildings, or area (whether or not enclosing a building or set of buildings) that is used for the lawful custody and/or treatment of individuals. It may be owned and/or operated by public or private agencies and includes the staff and services as well as the buildings and grounds.

    1. Under the provisions of South Dakota law, the following items are declared contraband inside a correctional institution. Guests will not introduce or attempt to introduce these items into this facility or at any location where an offender is likely to be located while such offender is in the custody and under the jurisdiction of a political suhdivision of the State of South Dakota or the Department of Corrections, but not on parole.

    1. Any dangerous instrument: A firearm, explosive device, or substance (including ammunition), knife or sharpened instrument, poison, acid, bludgeon, or projective device, metal utensil/drinking straw, or any other device, instrument, material, or substance which is readily capable of causing or inducing fear of death or bodily injury, the use of which is not specifically authorized.
    2. Alcoholic beverages.
    3. Controlled substances.
    4. Key pattern, key replica, or lock pick.
    5. Any tool or instrument that could be used to cut fence or wire, dig, pry, or file.
    6. Any un-canceled postage stamp or implement of the United States postal service.
    7. Any counterfeit or forged identification card.
    8. Any combustible material.
    9. Any drug, other than a controlled substance, in quantities larger than two (2) doses unless otherwise prescribed.
    10. Any mask, wig, disguise, or other means of altering normal physical appearance which could hinder ready identification.
    11. Any drug paraphernalia: all equipment, products, and materials of any kind which are used, intended for use, or designed for use in planting, propagating, cultivating, growing, harvesting, packaging, repackaging, storing, containing, concealing, injecting, ingesting, inhaling, or otherwise introducing into the human body a controlled substance in violation of the laws of this state.
    12. Any chain, rope, or ladder.
    13. Any cigarettes, tobacco products, chewing tobacco, vape pens/devices, or vape cartridges.
    14. Any Bluetooth enabled device and/or portable electronic communication device including but not limited to cell phones, smart glasses, smart watches, public, private, or family style radios, pagers, personal digital assistants, any other device capable of transmitting or intercepting cellular or radio signals, and portable computers; except those devices issued and authorized by the SDDOC.
    15. Any article or thing that poses or may pose a threat to the security of the SDDOC facility/office as determined by the warden. This shall include but not be limited to: matches, cigarette lighters, any substances used for brewing or making intoxicating beverages, any counterfeit or forged medium of exchange, or paraphernalia used to produce this medium, any batteries, cameras, film, flashbulbs, flashlights, pets (unless authorized through a facility dog program), plant life, or any article or substance that is not specifically allowed by this facility.

    1. Penalties:

    1. Anyone violating section A is subject to an investigation and may be barred from the facility and is subject to criminal prosecution.

    1. Declaration of Consent and Waiver:

    1. Any person entering a DOC facility without a permanent DOC ID badge will have a background check completed, prior to entry into a facility or onto DOC owned property. When possible, a completed copy of this form, must be received ten (10) days in advance of the anticipated date of access.
    2. As a condition of entering the property of South Dakota Department of Corrections, I hereby consent to search of my person and/or any of my personal property, or of the person of any minor children accompanying me. I also acknowledge any vehicle that I may bring on the grounds of this facility may be searched when reasonable suspicion arises that I have/am violating DOC policy/SD law as it relates to the introduction of contraband. I acknowledge that I have the opportunity to leave the facility immediately if I choose not to give this consent to search.
    3. I hereby declare that I have read and understand and will abide by the provisions above. I understand that violation of any of the above provisions, or the entering of any false information on this form may result in my being banned from or denied access to any of the South Dakota Department of Corrections' facilities.

  • Section 1: Guest Data

  • Date of Visit
     - -
    2 digit month, 2 digit day, 4 digit year

  • Section II: Guest Vehicle Data

    If you were a passenger, you must identify the car in which you arrived.

  • Section III - Guest Data

  • Date of Birth
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • The information I have provided is correct and I have read and understand the Declaration of Consent and Waiver.
  • Date:
     - -
    2 digit month, 2 digit day, 4 digit year

  • Department of Corrections
    Administration Office
    Kellie Wasko, Secretary
    3200 East Highway 34
    Pierre, SD 57501
    60S-773-3478
    Kellie.Wasko@statesd.us

    Volunteers, Contract Staff, and On the Job Trainees:

    The SDDOC requires completion of an 8-hour, on-line training course prior to entrance of a prison facility. The online courses consist of the following six videos listed below that must be viwed in their entirety. The topics must also be understood to ensure the safety of both staff and inmates.

    Upon completion of the 8-hour course, please acknowledge the statements below. Your signature signifies that you have completed the course and understand the concepts.

    I certify that I have viewed and understand the following trainings in their entirety:

    • Welcome to the SD Department of Corrections
    • The Shield of Professionalism
    • Stress, Burnout, and Hostage Survival
    • Prison Rape Elimination Act
    • Offender Supervision and Safety
    • Games Offenders Play
    • Key & Tool Control


    I understand the rules and regulations outlined by the South Dakota Department of
    Corrections. I understand that I am permitted to enter a prison facility, but the videos are not to replace the entire SDDOC training required by certain staff members.

    I understand that if 1 am an On the Job Trainee. I am permitted to job shadow with a trained staff member as an escort. Prior to basic training 1 understand that I shall never be left alone with inmates. Any questions I had regarding the videos were addressed with SDDOC.

  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
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