2026 GSP Chaperone Registration

Please read the following before beginning the registration:

"*" indicates required fields

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Chaperone Information

Chaperone 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

Gender*

Birthdate*

Month

Day

Year

Chaperone Email*

Enter Email Confirm Email

Name of Parish/School Chaperoning*

Chaperone Mailing Address*

Street Address Address Line 2 City State ZIP Code

T-Shirt Size*

How many GSPs have you attended?*

Emergency Contact Information

Emergency Contact's Full Name*

First Last

Emergency Contact's Primary Phone*

Please enter only the one best number here and please include the area code, e.g.: XXX-XXX-XXXX

Emergency Contact's Secondary Phone

Please enter only the one best number here and please include the area code, e.g.: XXX-XXX-XXXX

Relationship to Participant*

Parent/Guardian, Caregiver ect.

Medical & Safety Information

GSP works to reasonably accommodate basic dietary requirements. If your child has extensive dietary restrictions/needs we may not be able to accommodate. If we are unable to accommodate – we will reach out about a plan where you provide food for your child and we provide a space in which to store it.

Health Insurance Provider*

Policy Number*

Primary Physicians Name*

Primary Physicians Phone Number*

Do you have an Dietary Restrictions or Food Allergies?*

Yes

Non Food Allergies (Environmental, Medicinal e.g.: Allergic to penicillin, Latex etc.)

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.) Write N/A if this does not apply.

Medications currently taking (please list)

Dosage and when taken (Tap the + to add more.)

Any Medical conditions we should be aware of?

Do you have any Physcial Restrictions?*

e.g.: asthma, diabetes, depression, ADHD

Yes

Physical Restrictions (please list)

(Tap the + to add more.)

Permission to administer OTC meds*

e.g.: Tylenol, Benadryl, etc.

Yes

Permission to seek emergency medical treatment*

Yes

Acknowledgements

Please read the acknowledgements and check the boxes to confirm you have read and agree to the statements they accompany.

Consent*

I agree to review to the Code of Conduct and sign off on agreeing to the terms.*

Click here to read the Code of Conduct

Safe Environment Program*

I agree to comply with all aspects of the Safe Environment Program of the Diocese of St. Petersburg.

Click here to read to review the Safe Environment Certification.

Background Check & Fingerprinting*

I acknowledge that I must have been finger-printed for and a passed a Background check for the Diocese of St. Petersburg to be eligible to be a chaperone.

Click here to read to review the Background Screening Process.

Dress Code*

I agree to abide by the dress code of the Good Samaritan Project.

Click here to read to review the dress code.

I acknowledge that participants are not permitted to have cell phones at the Good Samaritan Project and my group leader will be responsible for enforcing this policy with the youth present. I confirm that I have read and agree to the cellphone policy.*

I Agree

I Do Not Agree

I agree that any minor that requests to call their parent will be given immediate access to do so by a chaperone without question.*

I Agree

I Do Not Agree

I acknowledge that participants and chaperones are required to follow dress code at all times, including but not limited to service sites, on-site programming, and pajamas. I confirm that I have read and agree to follow this dress code and enforcing this dress code.*

I Agree

I Do Not Agree

I acknowledge that participants must follow the DOSP Code of Conduct at all times and I confirm that I will enforce this code at all times. *

I Agree

I Do Not Agree

I acknowledge that the Good Samaritan Project is a Catholic experience faithful to the teachings of the Church and will include times of prayer and teaching for all participants and chaperones.*

I Agree

I Do Not Agree

I acknowledge that the Good Samaritan Project is a social justice focused service experience that will include service work including sites that are outdoors for all participants and chaperones.*

I Agree

I Do Not Agree

I acknowledge that participants and/or chaperones that do not follow these terms, or any of the GSP policies, will be dismissed from the program without a refund.*

I Agree

I Do Not Agree

I acknowledge that the chaperone's responsibility is to the attend to the supervision and safety of young people at all times- including over night. *

I Agree

I Do Not Agree

I affirm that I have no health restrictions that would prevent me from fulfilling my role as a chaperone, sleeping on an air mattress, and/or participating in service sites safely. *

I Agree

I Do Not Agree

Registration is Not Guaranteed. I acknowledge that my spot as a chaperone is not officially reserved until confirmed by both my parish youth minister and the Good Samaritan Project.