| *Date |
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| *Church Parish in which you are Registered |
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| *Name (First & Last) |
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| *Home Phone |
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| Work Phone |
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| Cell Phone |
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| *Street Address or P.O. Box |
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| *City |
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| *Zip Code |
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| * Do you have Diocesan Certification? |
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| If you do have Diocesan Certification, which level? |
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| * Have you had a Background Check through the Diocese of Baton Rouge |
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| Name of Diocesan Church or School where Background Check processed |
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| * Have you completed the Diocesan online safe environment training or previously attended a Child Protection Class? |
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| If yes, what is the date of the class |
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| I am interested in being a FACILITATOR for .. |
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| Grade I would like to Facilitate .. |
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| I am interested in being an ASSISTANT for .. |
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| Grade I would like to be an Assistant .. |
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| I am interested in being a MENTOR for Youth CONFIRMATION. I prefer .. |
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| I am interested in being a MENTOR ASSISTANT for Youth CONFIRMATION. I prefer .. |
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| Contact me about volunteering for .. |
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| Email Address |
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* Indicates required fields |
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