"*" indicates required fields Chaperone InformationChaperone Full Name* First Last Suffix Chaperone Preferred First Name*Appropriate names only will be used on his/her nametag instead of their First Name. Please do not include the last name in this field. First Birthdate*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender*MaleFemaleChaperone Email* Enter Email Confirm Email Name of Parish/School Chaperoning*Bishop McLaughlin Catholic High SchoolBlessed Sacrament, SeminoleChrist the King Catholic Church, TampaOur Lady of Grace Catholic Church, Beverly HillsOur Lady of the Rosary Catholic Church, Land O'LakesSt. Anthony of Padua Catholic Church, San AntonioSt. Jerome Catholic Church, LargoSt. Mark the Evangelist Catholic Church, TampaSt. Michael the Archangel Catholic Church, ClearwaterSt. Paul Catholic Church, TampaSt. Rita Catholic Church, Dade CitySt. Stephen Catholic Church, RiverviewTampa Catholic High SchoolSt. Catherine of Siena Parish, ClearwaterSt. Matthew ChurchNativity Church, BrandonEpiphany of Our Lord Parish, TampaChaperone Mailing Address* Street Address Address Line 2 City STAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code T-Shirt Size*SmallMediumLargeX-Large2X-Large3X-Large4X-LargeHow many GSPs have you attended?*01234+Emergency Contact InformationEmergency Contact's Full Name* First Last Emergency Contact's Phone*Please enter only the one best number here and please include the area code, e.g.: XXX-XXX-XXXXDietary and Medical InformationDo you have an Dietary Restrictions or Food Allergies?* Yes No The leaders of the Good Samaritan Project will provide, to the best of their ability, special meals where medically required. We will try to provide alternatives but are not able to provide special meals based on nutritional lifestyles or choices. GSP cannot rule out cross-contamination of medically required meals. If dangerous allergic reactions could occur, GSP suggests those participating consult with their group leader about bringing supplemental food.Dietary Restrictions/Food Allergies* Gluten-Free Dairy-Free Vegetarian Vegan Nut Allergy Other Please Specify Allergy/Restriction Type*e.g.: Allergic to mushrooms, almonds and strawberries (Tap the + to add more.)Allergy Add RemoveDo you have any Medicinal Allergies?*e.g.: Allergic to penicillin Yes No Medicinal Allergies*(Tap the + to add more.) Add RemoveDo you have any Physcial Restrictions?*e.g.: asthma, diabetes, depression, ADHD Yes No Physical Restrictions*(Tap the + to add more.) Add RemoveAcknowledgementsPlease read the acknowledgements and check the boxes to confirm you have read and agree to the statements they accompany.Consent* I acknowledge that I have read the code of conduct and agree to its terms.*Consent* I acknowledge that I have read and received the participant packing list.*Consent* I acknowledge that I must be Safe Environment Trained through the Diocese of St. Petersburg (DOSP), fingerprinted, and pass a background check prior to chaperoning.*Consent* I agree to adhere strictly to safe environment policies in order to provide for the care and supervision of minors.*Consent* I acknowledge that I, and other DOSP cleared chaperones, are responsible for the protection/supervision of young people at service sites in addition to all other GSP programming.*Consent* I acknowledge that I have reviewed the dress code and agree to adhere to what is found within as well as enforce this policy with the minors I am chaperoning as per the policy of my youth leader.*Consent* I acknowledge that I have reviewed and agree to the terms of the leader guide including the FAQs.*Consent* I acknowledge that I will be expected to sleep on a twin air mattress on a classroom floor and will be responsible for the protection/supervision of teens from my parish/school in the evening as well as during the day. I agree that I am free from any limitations that would prevent me from reasonably fulfilling these expectations.*Consent* I acknowledge that minors will not be permitted the use of their personal cell-phones on the Good Samaritan Project and I agree to enforce this policy. If a minor needs to call a parent/guardians they may utilize the cell phone of a group leader at any time. Click here to review the cell phone policy.*Consent* I recognize that I will be expected to be present to chaperone for the duration of GSP (unless I have explicit written agreement with my youth leader.)*EmailThis field is for validation purposes and should be left unchanged.