Guest Speaker Request Form
Thank you for your willingness to speak to our school community. Having outside voices and expert perspectives on topics of interest to our community enriches us. Diocesan policy requires us to ensure safe-environment compliance with any guest to our campus during school hours. This form is intended to provide basic details about your visit and confirm your eligibility to work with minors.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Affiliation (Organization/Institution)
*
Topic of Presentation
*
Date of Visit
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time of Visit
*
Hour Minutes
AM
PM
AM/PM Option
Special Requirements (optional)
Full legal name (as shown on your government-issued photo ID)
*
First Name
Last Name
Date of birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Have you ever been convicted of, pled guilty to, or pled no contest to any felony, or to any misdemeanor involving violence, a sexual offense, a controlled substance, or a minor? You may exclude any record that has been sealed or expunged and any traffic offense other than DUI.
*
No
Yes
Explanation (if you answered yes to any question above)
Are you currently required to register as a sex offender or sexual predator in any state?
*
No
Yes
Has any court, employer, school, licensing body, or religious organization ever restricted, suspended, or prohibited you from working or volunteering with minors?
*
No
Yes
Certification
*
I certify that the information above is true and complete. I understand that at check-in I will be asked to present a valid government-issued photo ID, which will be checked against state and national sex offender registries, and that Chesterton Academy of The Florida Martyrs may deny campus access based on the result or on any information disclosed above.
Submit Request
Should be Empty: