Dear Chaperone,
Thank you for your willingness to be a part of this activity. Many of our school’s activities would not be
possible, if not for parents and community members who volunteer to ensure the safety of our students and
educational value of our activities.
To help ensure the safety of our students, it is necessary to clearly define the expectations that we have
for our chaperones. While these expectations are not intended to limit your personal freedoms, the safety and
education of our students must take precedence.
Conduct:
-No inappropriate language, jokes, suggestions, or gestures.
-Do not take a picture, video, or record students in any fashion, other then your own child.
-Do not be alone with a student in an isolated area (for example: being alone with a student in a hotel
room).
-Do not take ANY substance that may impair your judgment (for example: alcohol, medication).
-Follow all local, state and federal laws.
-Do not allow or facilitate students breaking school policies and rules.
-Do not allow or facilitate students breaking the law.
-Make the safety of the students your highest priority.
If you see or suspect that a student is breaking a school policy or the law, it is your responsibility to inform your
group leader immediately.
It is the group leader’s responsibility to provide disciplinary action as needed.
If you believe that a student’s health is in danger, take all appropriate action and inform the group leader.
If you believe that the group leader has not followed school policy, please contact the principal as soon as
possible.
Other Policies – Only the principal can provide exemptions to any of the stated policies.
-Students must stay in hotel rooms separate from adults. This includes parents.
-A chaperone must be with the students at all appropriate times. The students cannot be left with other
adults/parents who are not on the official chaperone list.
-Students must be grouped with at least 2 other students for all activities.
-Transportation can only be provided through the prior approved list of drivers and vehicles.
Complete the Volunteer Profile Form on the back of this form. The volunteer profile form only has be
completed once each school year, unless information changes. Once this information is accepted, you will be
placed on a list of approved chaperones and drivers for the remainder of the school year for any field trip for
any group. There is two notable exceptions, if you are asked to drive or for overnight field trip. In these cases,
you will be given new forms.
Iredell-Statesville Schools
VOLUNTEER PROFILE FORM
The Iredell Statesville Schools has developed a volunteer/chaperone screening process to help ensure the safety of our children.
Chaperones for day field trips should complete section I and II of this form and return it to the school principal at least 7 days
before the date of the field trip. You may read a copy of School Board Policy 3320 by visiting our website (www.iss.k12.nc.us).
Section 1: Volunteer Contact Information
Trip Date: ___________________
Date __________________ Student Name_____________________________ School Name ____________________Grade______
First Name _________________________ Middle/Maiden ___________________ Last Name ______________________________
Home Address, City, State, Zip __________________________________________________________________________________
Home Phone _______________________________________ E-mail Address ____________________________________________
Employer __________________________________________ Business Phone ___________________________________________
Business Address, City, State, Zip _______________________________________________________________________________
Have you ever been employed by I-SS?
Yes
No
If yes, give dates of employment:
_____________________________
Section 2: References
Please print. Complete the following information for three non-family references.
1.
Name__________________________________________________ Relationship __________________________________
Address _____________________________________________________________________________________________
Street
City
State
Zip
Phone____________________________________ How long have you known this person? __________________________
2.
Name__________________________________________________ Relationship __________________________________
Address _____________________________________________________________________________________________
Street
City
State
Zip
Phone____________________________________ How long have you known this person? __________________________
3.
Name__________________________________________________ Relationship __________________________________
Address _____________________________________________________________________________________________
Street
City
State
Zip
Phone____________________________________ How long have you known this person? __________________________
I authorize I-SS to contact the references I have listed.
_________________________________________
Signature
Date
_____________________________