APPLICATION FOR REQUIRED VOLUNTEER HOURS
Archdiocese of Miami
Dear Volunteer
Thank you for offering your time and talent to work with the youth of our parish/school. Volunteers
such as you are indispensable to our programs. This application is used by the parent completing the
minimum required 10 volunteer hours.
We truly dislike troubling you but we know you will understand that we face possible liabilities if we do
not make appropriate inquires of those to whom the care of our young people is committed. Please
supply the information requested below and return this form to your Director of Religious Education,
your Youth Minister, Principal, or the parish/school office.
Personal Information (please print):
Name: _________________________________ Social Security #: _______________________
Address: ___________________________ City: _______________ State: ____ Zip: _________
Date of Birth: _______________________________
Work Phone #: __________________________ Home Phone #: _________________________
Driver’s License # _______________________________________ State: __________________
Parish: _______________________________________________________________________
Marital & Family Status:
_____Single ______Married _____Widowed _____Separated _____Divorced
If married, please answer the questions below:
Name of Spouse: _______________________________________________________________
Were you married in the Roman Catholic Tradition? ______ Yes _______ No
If no, please give the circumstances: ________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Application for Required Minimum 10 Hours - Page 1 of 8
Religious Information:
Baptism: ___ Yes/___ No Parish: __________________City:__________ State: ____
First Communion:___ Yes/___ No Parish: __________________City:__________ State: ____
Confirmation: ___ Yes/___ No Parish: __________________City:__________ State: ____
Education Information:
Elementary Completed ___ Yes/___ No
High School Completed ___ Yes/___ No
College: ___ Yes/___ No
Graduate Work: ___ Yes/___ No Specialization ______________________________
Do you have any history of:
Alcohol or drug abuse ___ Yes/___ No
Mental Illness ___ Yes/___ No
Contagious disease(s) ___ Yes/___ No
Have you ever been arrested? ___ Yes/___ No
Have you ever been accused of child neglect or abuse? ___ Yes/___ No
Has your driver’s license ever been suspended or revoked? ___ Yes/___ No
Probation ___ Yes/___ No
Please explain if any answer is “Yes”: ______________________________________________
__________________________________________________________
Prior experience working with youth: (Please check those that apply)
_____Children (5-10) Explain ____________________________________________________
__________________________________________________________________
Name, address and phone number of your Supervisor: __________________________________
__________________________________________________________________
_____Youth (11-14) Explain ______________________________________________________
__________________________________________________________________
Name, address and phone number of your Supervisor: __________________________________
__________________________________________________________________
_____Teens (15-18) Explain ______________________________________________________
__________________________________________________________________
Name, address and phone number of your Supervisor: __________________________________
__________________________________________________________________
What would you say are your strongest gifts? ________________________________________
__________________________________________________________________
Application for Required Minimum 10 Hours - Page 2 of 8
Please state in your own words what prompted you to volunteer your services with this program.
_____________________________________________________________________________
__________________________________________________________________
References: Please list names, addresses, and phone numbers of those who are familiar with your
character as it relates to work with youth. Three (3) non-family references please excluding Pastor and
Staff).
Name Phone Address
1. _______________________________________________________________________
2. _______________________________________________________________________
3. _______________________________________________________________________
A. The information that I have provided may be verified, if necessary, by contacting persons or
organizations named in this application, or by contacting any person or organization that may
have information concerning. I hereby release and agree to hold harmless from liability any
person or organization that provides information. I also agree to hold harmless the local parish,
the Archdiocese of Miami, and the officers, employees, and volunteers thereof.
B. In signing this application, I affirm that the information I given is true and correct. Furthermore,
I understand that volunteering is contingent upon a background screening.
Signature of Applicant: ___________________________________________
Date: _____________________________
Application for Required Minimum 10 Hours - Page 3 of 8
VOLUNTEER DRIVER QUESTIONNAIRE
Archdiocese of Miami
(Please complete even if your present volunteer request does not include being a driver.)
Driver’s Name: ____________________________________________________________
Address: _________________________________________________________________
City: ______________________________ State: ________ Zip: _________
*****************
Car Insurance Carrier: _______________________________________________________
Address: _________________________________________________________________
City: ______________________________ State: ________ Zip: _________
Policy Number: _____________________________________________
(Please attach a copy of the declaration page)
Vehicle: _________________________ Type: _____________ Year: ______
Condition of Vehicle: _______ Good _______ Fair _______Poor
Type of License: __________________________________________________________
Car Owner’s Signature: _____________________________________________________
Date: ____________________________
Application for Required Minimum 10 Hours - Page 4 of 8
VOLUNTEER/EMPLOYEE ATTESTATION OF GOOD MORAL CHARCTER
Archdiocese of Miami
I, _____________________________________, a prospective or current employee, volunteer,
seminarian, priest or deacon, religious brother or sister, hereby attest, under penalty of perjury, to
meeting the requirements for employment, that I am of good moral character, and that I have not been
found guilty of, regardless of adjudication, or entered a plea of nolo contendere or guilty to, any offense
(or attempt or conspiracy thereunder) prohibited under any of the following provisions of the Florida
Statutes or under any similar statute of a similar jurisdiction. I also attest that I do not have a
delinquency record that is similar to any of these offenses.
1. Section 782.04, 782.07, 782.071 and 782.09, relating to murder, manslaughter, aggravated manslaughter
of an elderly person or disabled adult, or aggravated manslaughter of a child, vehicular homicide, or
killing of an unborn child by injury to the mother;
2. Sections 787.021, and 784.045, relating to kidnapping, false imprisonment or removing minors from the
state or concealing minors contrary to court order;
3. Sections 787.01, 787.02 and 787.04, relating to kidnapping, false imprisonment or removing minors from
the state or concealing minors contrary to court order;
4. Section 794.011, relating to sexual battery;
5. Chapter 796, relating to prostitution;
6. Section 798.02 and Chapter 800, relating to lewd and lascivious behavior and indecent exposure;
7. Section 806.01, relating to arson;
8. Section 826.04, relating to incest;
9. Sections 827.03, 827.04, 827.05, and 827.07, relating to child abuse, aggravated child abuse, neglect of a
child, negligent treatment of children, contributing to the delinquency or dependency of a child, and
sexual performance by a child;
10. Chapter 847, relating to obscene literature:
11. Section 415.111, relating to adult abuse, neglect or exploitation of aged persons or disabled adults;
12. Chapter 893, relating to drug abuse prevention and control, only if the offense was a felony or if any other
person involved in the offense was a minor;
13. Section 817.563, relating to fraudulent sale of controlled substances, only if the offense was a felony;
14. Chapter 776, relating to forcible felony;
15. Section 784.0111, relating to assault, if the victim of the offense was a minor;
16. Section 784.03, relating to battery, if the victim of the offense was a minor;
17. Formers. 794.041, relating to prohibited acts of persons in familial or custodial authority;
Application for Required Minimum 10 Hours - Page 5 of 8
VOLUNTEER/EMPLOYEE ATTESTATION OF GOOD MORAL CHARCTER – Page 2
Archdiocese of Miami
18. Sections 825.102, 825.1025, and 825.103 relating to abuse, aggravated abuse, or neglect of any elderly
person or disabled adult, lewd or lascivious offenses committed upon or in the presence of an elderly
person or disabled adult and exploitation of an elderly person or disabled adult, if the offense was a
felony;
19. Chapter 812, relating to theft, robbery, and related crimes, if the offense is a felony;
I understand that I must acknowledge the existence of any records relating to the foregoing list of offenses
regardless of whether those records have been sealed or expunged. I also understand that I am also obligated
to notify my supervisor of any possible disqualifying offenses that may occur while employed in a position
subject to the screening requirements.
I further attest that:
I have not been judicially determined to have committed abuse, neglect, or exploitation against a child as
defined in section 39.01 nor has there been a confirmed report of abuse, neglect or exploitation as defined in
415.102(5) or 415.503, which has been uncontested or upheld pursuant to the procedures of 415.103. I have
not committed an act which constitutes domestic violence as defined in 741.30.
I understand that my contract is contingent upon a background screening. I understand that said screening
will include, but not be limited to, employment history checks and statewide criminal correspondence checks
through the Florida Department of Law Enforcement, and may include local criminal records checks through
local law enforcement agencies. I also understand that the background check may include fingerprinting,
statewide records checks through the Federal Bureau of Investigation.
I authorize the Archdiocese of Miami, its employees and agents, to make inquiries, including criminal
history, employment history and driving history. I hereby release and agree to hold harmless from liability
and person(s) or organizations, who, in good faith, provide information to complete a background
investigation. I also agree to release and hold harmless the local parish, the Archdiocese of Miami, the
Archbishop, and the officers, employees and volunteers thereof from any present or future claim of any kind
resulting from any alleged liability for conducting a background investigation which may include, but no
limited to, criminal courts, state and county repositories of criminal records.
Under the penalties of perjury, I declare that I have read the foregoing, and the facts alleged are true to the
best of my knowledge and belief.
__________________________________ ______________________________________
Name (please print or type) Signature
Application for Required Minimum 10 Hours - Page 6 of 8
Archbishop Edward McCarthy High School
“The elements for a Safe Environment Program” of the Archdiocese of Miami requires that adults working with youth and vulnerable persons read and sign
a code of conduct.
CODE OF CONDUCT
All employees and volunteers in the schools of the Archdiocese of Miami in their roles as agents of the Archdiocese are
committed to the following code of conduct with covers activities in which they are working with youth or vulnerable
persons.
1. To be conscious of the unique power which an adult holds due to the trust placed in them by way of service to young
and vulnerable persons.
2. To assume the full burden of responsibility for setting and maintaining clear and appropriate physical and emotional
boundaries with young or vulnerable persons.
3. To be proactive in identifying young and/or vulnerable persons who may be vulnerable or at risk of unhealthy
relationships and to assist them in developing their sense of self-worth and avoiding emotional manipulation.
4. To avoid any covert or overt sexual behavior with youth or vulnerable persons. This includes seductive speech or
gestures as well as physical contact that sexually abuses, exploits, or harasses a person.
5. To never initiate sexual behavior with a minor or vulnerable person and to refuse it even when the other invites it.
6. To show prudent discretion in the expressions of affections used with young and vulnerable persons.
7. To avoid forms of touch which could be construed as sexual with a young or vulnerable person, except when this
part of one’s professional responsibilities.
8. To assure that a meeting space with a student or vulnerable person has visual access.
9. To never lock the room when a teacher is the only adult present with youth or vulnerable persons except when for
reasons of safety, the administration has directed this to be done.
10. Not to drive alone with a young or vulnerable persons unless there is a verified authorization from the guardians to
transport them.
11. Not to share a bedroom with a young or vulnerable person.
12. Never to provide young or vulnerable persons with alcohol or with videos, reading or graphic materials that are
inappropriately sexual in nature.
13. Not to be under the influence of illegal drugs nor intoxicated by alcohol when engaged in ministry to young or
vulnerable persons.
14. Not to engage in a personal relationship over the internet with a student or vulnerable person.
15. To understand that it is an adult’s responsibility under the law of the State of Florida to report to the Department of
Children and Families any situation where there is good reason to believe that a minor or vulnerable adult has been a
victim of sexual or physical abuse, and then to inform the principal about the report.
16. To comply with the youth to adult ratio required by the institution or department under which my program operates.
17. I agree to follow this code of conduct in my relationship with minors and vulnerable adults when I am acting in my
role as agent of the school.
_____________________________ __________________________________
Printed Name Signature
_____________________________ __________________________________
Institution Date
Application for Required Minimum 10 Hours - Page 7 of 8
TYPICAL PARTICIPATION FORM
RELEASE AND HOLD HARMLESS AGREEMENT
Date:__________
I , am aware that Archbishop Edward A. McCarthy High
School, Inc. and the Archdiocese of Miami, Archbishop John Favalora, and his successors are
not responsible for any injury while participating __________________ here at Archbishop
Edward A. McCarthy High School.
In signing this document I , recognize that Archbishop Edward
A. McCarthy High School, Inc. and Archdiocese of Miami (A.D.M.) would not give permission
to participate in _____________________unless I acknowledge full responsibility in assuming
any risk of injury and am covered by my own health insurance policy.
I hereby agree that the employees, officers, volunteers, or
independent contractors of Archbishop Edward A. McCarthy High School, Inc. and the
Archdiocese of Miami shall not be liable for any damages arising from personal injuries or
damage to property which I may sustain in any way in, on or about the premises of Archbishop
Edward A. McCarthy High School, Inc. or anywhere else where the activities may occur before,
after or during the activity in which I am Participating in. Also, I_______________________
realize there will be no athletic trainer on the grounds and am participating at my own risk.
I will assume full responsibility for any injuries and/or damages I cause and I do hereby fully and
forever release and discharge Archbishop Edward A. McCarthy High School, Inc. and
Archdiocese of Miami, its employees, officers, volunteers and independent contractors from any
and all claims, demands, damages, right of action or causes of action present or future.
______
Witness Participant’s Signature
Parent’s Signature Participant’s Printed Name
Application for Required Minimum 10 Hours - Page 8 of 8