59th Annual Teen Conference
June 27 – June 30, 2013
Arizona State University • Tempe, Arizona
Hosts: Phoenix & Tucson Chapters
CHAPERONE RESPONSIBILITIES
There MUST be ONE Registered Chaperone for every FIVE teens by gender.
A. DUTIES:
PRIOR TO LEAVING FOR TEEN CONFERENCE
 Review “Code of Ethics” with the teens under your direct supervision
UPON ARRIVAL
 Check in at J&J Registration Desk following the instructions of the Lead Chaperone
 Assist teens with their room keys and room assignment
 Check rooms and note condition (towels, blankets, etc.)
 Will check rooms each night at curfew to assure that all of the teens under her/his care are in their rooms and conducting
themselves appropriately.
 Make sure that the teens within your care are on time
THROUGHOUT THE CONFERENCE
 Will ensure the teens in your care are abiding by the rules and code of ethics of Teen Conference
 Will ensure the teens are dressed appropriately BEFORE leaving their dorm rooms.
 Will get the teens to all meetings, meals and functions on time
 Will enforce proper dance etiquette
 Will coordinate chaperone duties with Lead Chaperone as needed for example share chaperone duties when attending
meetings
UPON DEPARTURE
 Reconfirm condition of each room
 Check rooms for personal items
 Collect keys and return to ASU Teen Conference registration desk
 Check out at ASU Teen Conference registration desk
B. RULES TO ENFORCE:









No drugs, alcohol or smoking by any FWR Teen Conference Participant
All participants will remain on ASU Campus as well as our off-site activities at Amazing Jakes/Children’s First Academy/
Mission Palms Hotel
No cars are to be driven by teen attendees
Attend all planned activities and meals
Attend all sessions and workshops
Should be in dorm rooms during free time ONLY with Chaperones knowledge
Male/Female visitations permitted only with DOOR OPEN
All teens return to ASSIGNED ROOMS at 1:00 AM Saturday morning and 1:30 AM on Sunday morning
All Rules as detailed in Code of Ethics
C. ATTENDANCE:



Chaperones MUST be in attendance at ALL Teen Activities (Plenary Sessions, meals, dances, workshops, etc) in proper dress
code and sit with their teens at plenary sessions.
Chaperones CAN NOT stay in their rooms and send their teens to activities
Chaperones CAN NOT leave campus and leave their teens unattended
D. CURFEW




Chaperones MUST enforce curfew every night
Chaperones must complete room checks nightly
After Curfew, POPS on PATROL will walk the area and ensure the safety of our teens
Any infractions that take place after curfew will be documented with an incident report
Infraction of any of the Rules and Regulations of the Conference will result in the teen’s appearance before the Teen Judicial
Board for major abuse. A possible result may be the dismissal of the teen from the conference. The Regional Director will inform
the involved Lead Chaperone and parent of the infraction, as well as punitive actions taken.
CHAPERONE CODE OF CONDUCT FORM
TO BE COMPLETED BY ALL TEEN CHAPERONES
NAME OF CHAPERONE:
CELL NUMBER:
CHAPTER:
EMAIL ADDRESS:
I will attend the conference as the chaperone for the teen(s) listed below and confirm that: (Please Initial)
I am aware of the duties of a chaperone in the Jack and Jill organization
I am aware of the Teen Code of Ethics included in this package
I will review the Teen Code of Ethics with the teens in my care upon arrival at the Teen Conference
I will be present on site for registration and the entire regional teen programming as outlined on the agenda
I am aware that no teens may leave the teen conference without the chaperone and the express permission
from the Regional Director
Chaperones are not to be consuming alcohol beverages during Teen Conference
Teens who have parents in attendance at the teen conference are still required to be with their chaperones,
check in with their chaperones and comply with the chaperone’s directives and or requests, including
permission to leave the area with their parents
I am aware that if any major and serious infractions of the aforementioned rules and regulations will result in
the teen’s appearance before the Teen Judicial Board. The Regional Director will inform the involved lead
chaperone and parents of the infraction, as well as, the punitive actions taken: dismissal and/or expulsion
TEENS UNDER MY DIRECT SUPERVISION: (Please Print)
Name of Teen
1.
2.
3.
4.
5.
SIGNATURE OF CHAPERONE: __________________________________________ DATE: __________________________
PLEASE RETURN COMPLETED FORM TO YOUR CHAPTER DROPBOX FOLDER:
If you need assistance in uploading your completed documents, please contact Regional Secretary Emma Turner at
fwr.sec.et@gmail.com
DUE DATE: April 26, 2013
59th Annual Teen Conference
June 27 – June 30, 2013
Arizona State University • Tempe, Arizona
Hosts: Phoenix & Tucson Chapters
AUTHORIZATION FOR EMERGENCY MEDICAL AND DENTAL TREATMENT
ADULT ATTENDEE
(Please review and sign both pages)
Registrant’s Name:
Chapter Name:
Teen Conference officials will notify your family or your designated representative should you become ill or injured. If no
one can be reached, you will be taken to the nearest emergency hospital unless your written instructions to the contrary
are on file at the conference site.
I, (Name of attendee)
hereby authorize any necessary medical, dental or surgical diagnosis, treatment, x-ray
examination, anesthetic, and/or hospital care to be rendered under the supervision and upon the advice of any
physician or dentist licensed by the State of California.
INSURANCE INFORMATION
(Required for all Registrants, Teens and Chaperones)
Name of Subscriber:
Health Insurance Group Name:
Subscriber Membership Number:
Dental
Type of Coverage :
PLEASE ATTACH A COPY (FRONT AND BACK) OF INSURANCE CARD(S) Medical and Dental
It is understood that this authorization is given in advance of any specific diagnosis, treatment, or hospital care being
required, but is given to provide authority and power on the part of the aforementioned agent(s) to give specific consent
to any and all such diagnosis, treatment, or hospital care which the aforementioned physician or dentist, in the exercise
of his/her best judgment, may deem advisable.
This authorization remains in effect from June 27 through June 30.
I understand that Far West Region, Jack and Jill of America, Incorporated and its adult members assume no liability of
any nature whatsoever in relation to any transportation of (name of registrant)
for the purpose of securing
medical and/or dental treatment described above. I further understand that all medical and dental treatment,
examinations, x-rays, cost of ambulance, or hospitalization provided in relation to this authorization shall be borne by
the undersigned.
Signed:
__________________________________________
Date:
Emergency Contact (Other than parent):
Relationship:
Street Address
City, State, Zip
Telephone (Day):
Telephone (Eve)
(Print Name of Adult)
Cell:
is allergic to the following medications:
does
does not have special needs
is
is not taking medication prescribed by a physician;
is
is not currently under a physician’s care.
Teen Conference officials are not responsible for administering any medications. If the registrant is taking medication
under a physician’s care or has special needs, please explain in detail:
PERMISSION WAIVER
I will participate in the activities of the Jack and Jill of America, Incorporated, 59th Far West Regional Teen Leadership
Conference from Thursday June 27 through June 30, 2013. I understand all precautions will be taken to ensure my safety
and I waive Jack and Jill of America, Incorporated of any liability of any nature whatsoever, in relationship to any injuries
or illness sustained by myself.
Signed:
________________________________________________________
Date:
The Adult Attendee MUST sign BOTH the Permission Waiver and the Authorization
for Emergency Medical Treatment in order to participate in the Conference.
All files must be uploaded by April 26, 2013.
If you need assistance, please contact Regional Secretary, Emma Turner at fwr.sec.et@gmail.com.