Relay for Life of Farmington Valley
Chaperone Agreement
The American Cancer Society’s Relay for Life of Farmington Valley requires two chaperones per student team.
Chaperones must be over the age of 25. For this event, a youth is considered anyone in grades K-12 regardless of age.
The Relay for Life of Farmington Valley requires chaperones to be on premises at all times that their team is present.
Remember to SIGN the form. All sections and fields must be completed
1
CHAPERONE NAME:
EMAIL:
ADDRESS:
CITY:
STATE:
CELL PHONE:
HOME PHONE:
ZIP:
Include school prefix before team name: FHS, SHS, AHS, LMHS, IAR, AMS, CMS, WW.
2
SCHOOL TEAM PREFIX:
TEAM NAME:
TEAM CAPTAIN:
I have read this document, I understand its contents, and I agree to its terms. I also understand that if I do not
follow the guidelines below, my participation in this American Cancer Society youth activity will be terminated.
3
CHAPERONE SIGNATURE:
DATE:
The following guidelines are designed to help volunteers understand what behavior is expected while performing within the course and scope of an American Cancer Society volunteer
leader/chaperone position. Volunteer leaders/chaperones are expected to abide by all American Cancer Society policies. The goal of this American Cancer Society youth activity is to
provide a safe, fun and positive experience for both youth and adults. As an adult participant, you play a valuable role in attaining this goal. Please read through this code of conduct and
sign below.
Adult volunteer / chaperone shall…
1. Respect the individual rights, safety, and property of others.
2. Not discriminate in any policies, procedures, or practices, on the basis of race, religion, color, national origin, sex, gender, marital status, sexual orientation, age, veteran status,
medical condition, or disability.
3. Have a valid driver’s license and carry proof of automobile liability insurance, if the volunteer leader is to use a motor vehicle to transport him- or herself or others. Also, insure
that all passengers use seatbelts.
4. Not possess or use alcohol and/or illegal drugs (or be under the influence thereof) while involved in any American Cancer Society event, meeting, or activity.
5. When chaperoning youth members, not leave the premises of the event unless they he or she has received the approval of the adult in charge or the event.
6. Not use obscene and discriminatory language at any American Cancer Society activity.
7. Represent the American Cancer Society to youth and adults by conducting themselves courteously in manner and language, exhibit good sportsmanship, serve as a positive role
model, and demonstrate reasonable conflict resolution skills.
8. Abide by all applicable American Cancer Society laws and rules, policies, and guidelines. This includes, but is not limited to, child abuse, fiscal management procedures, and
substance abuse.
9. Accept supervision and support from salaried staff or designated management volunteers.
10. Accept the responsibility to promote and support the vision, mission, and values of the American Cancer Society.
11. Ensure that youth team members also follow ground rules and participate fully in all Relay For Life activities.
12. Participate in activities to the best of his or her ability, as well as attend at least one Relay For Life team captain meeting.
13. Chaperones will be notified of any violations of the ground rules. If the problem persists, the youth team member will be asked to leave the premises for the remainder of the
event. In some cases, this may necessitate calling the emergency contact person.
14. Appreciate the valuable role that youth play in the American Cancer Society.
Farmington Valley Relay for Life requires every student team to have two chaperones on-site throughout the time that the team is at the Relay As a chaperone:
1. I am required to be on-site during my time slot. On arrival, I’ll report to the Chaperone Station across from Registration. I will sign in at the beginning of my scheduled time and
sign out at the end of my scheduled time. The Chaperone station will be staffed from 7 a.m. until 11 p.m. Chaperones will sign in and out at the Security tent after 11 p.m.
2. I will keep track of student team members’ whereabouts and make sure they follow the ground rules.
3. I will report any problems to the Security staff or Relay committee members (identified by their colored t-shirts).
4. I will review the Student Emergency Contact List for my team. This is a complete list of student team members and parent/guardian contact numbers for each participant, to be
used in case of emergency, and is available from the team captain or team Chaperone Captain.
5. Smoking, alcohol and drugs of any kind are not permitted at the Relay. If I suspect alcohol or illegal drug use is present, I will anonymously notify security or a committee
member (identified by their colored t-shirts) immediately. They will handle the situation accordingly.
6. Pets are not allowed. Service animals specifically trained to aid a person with a disability are welcome.
The following apply to high school team chaperones:
7. As a Chaperone I will make sure that team members sleep only at their assigned campsite. I will be attentive in preventing co-ed sleeping situations.
8. If student team members are awake during quiet hours, they must remain in areas designated for nighttime activities.
9. Students are not allowed to leave and return to the Relay site during overnight hours without authorization. If a student must leave, I will escort them to sign out at the Security
station and I must contact the student’s parents.
The American Cancer Society Relay for Life of Farmington Valley Leadership Team Thanks You for Your Participation!
You are helping the students participate in a unique volunteer experience.