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. This form includes your permission to perform a
background check, which is required by ISS board policy for all adult chaperones on overnight school trips. The
cost of the background check is $25.00. Your group may ask you to reimburse this expense.
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
Section 3: Background Check Information and Consent
BACKGROUND CHECK RELEASE AUTHORIZATION
In consideration of my application to volunteer, I authorize Iredell-Statesville Schools by and
through North Carolina Administration of the Clerk of Courts and/or by and through QPI or
another selected agency or source to verify all data given by me on application, related papers
or oral interviews. I understand a thorough investigation may be conducted which may
include, but not be limited to criminal history, motor vehicle driving record. I state that the
information provided by me on my application is accurate and I agree that if any information
therein is found to be false at any time, my application may be discarded. I understand that
the information requested below regarding sex, race and date of birth are for the sole purpose
of gathering the above information accurately and will not be used to discriminate against me
in violation of the law. A facsimile (Fax) or photocopy of this authorization shall be as valid
as the original.
___________________________________________
Applicant’s Full Name (Please Print)
__________________________________________
Social Security Number
___________________________________________
Maiden or other names used
___________________________________________
Date of Birth
Race
Sex
___________________________________________
Driver License Number/
State issued
___________________________________________
Applicant’s Signature
Date
This form must be filled out in its entirety. We do not share information and will keep your confidential information private. You DO
have to provide us your social security number for our check. If this is left blank, a check will not be performed. If you have questions
about this process please call Alisha Johnson at 704-924-2053.
Do you plan on transporting students? ___________
If yes, please provide a copy of your driver’s license and current insurance card.
Is this an overnight field trip?
Yes_______
No_______
Have you have chaperoned on an overnight field trip before and we have already performed an
initial background check? Yes________ NO________ if yes, when? ____________
Iredell-Statesville Schools maintains certain records on volunteers. In accordance with Section 115C-209.1 of the North Carolina
General Statutes, those records are not public records and shall not be open to inspection, except in accordance with that law. A copy
of this law can be seen on the I-SS website (www.iss.k12.nc.us.).
***For Office Use Only***
RECD:
SSN Scan___________
Fax Profile Form to: 704-872-2553 attn: Alisha Johnson
COMPLETED:
HRMS:
Comments/Approval:
Alias_______________
NC________________
OOS_______________
special instruction needed___________________
Rev. 03/18/2010