Chaperone Agreement Form

Leaving Campus Protocol

Any boarding students leaving campus with someone other than a staff member must comply with the following:

If the student is leaving campus with someone other than their legal guardian, they must have a signed waiver giving written parental permission to leave campus with and be chaperoned by an adult friend of the family (aged 21 or older) or close relative (aged 18 or older). The student must also be returned to the campus by the same designated chaperone.
If the student is leaving campus with someone other than their legal guardian, the adult chaperoning the student must also sign a chaperone agreement.
The signed waiver and chaperone agreement must be turned in to the Director of Residential Life no later than the prior Wednesday.
If a student will be off campus for 6 hours or longer, or if they are spending the night at the home of a friend or family member, they must additionally complete a weekend leave of absence form (also due the prior Wednesday).
If a staff member drives the student off campus for such a leave, they must turn the student over to the specific adult chaperone who has been named in the waiver and who has signed a chaperone agreement.
Students may not walk, bike or use a ride-sharing service (Uber, Lyft, etc.) to or from the campus.
Students must sign out using the sign-out log.
Students must get approval in advance if they will be off campus during required activities.
Students are responsible for coordinating their absence with their team coach, choir director, club leader, etc., before they miss a meeting, practice, or rehearsal.
In all cases, the student’s return time back to campus must be prior to dorm check, and the student must check in with the staff rover upon returning.

Failure to follow any of the above guidelines may result in loss of the privilege to leave campus or more serious consequences.

Chaperone Agreement Form

Required

Student's information:

Please list the first and last name of each student you will be chaperoning off campus

Trip information:

Purpose of the trip:required

I will be hosting the above student(s) off campus forrequired

for a few hours, but returning on the same day by dorm check

staying overnight

We will be departing campus on:required

Must contain a date in M/D/YYYY format

And returning to campus on:required

Must contain a date in M/D/YYYY format

Campus departure time:required

Campus return time:required

Chaperone's Information:

A chaperone is an adult (over the age of 21) assuming responsibility for the student.

Chaperone's Namerequired

First Name

Last Name

Chaperone's phone number:required

Chaperone's Email Addressrequired

Chaperone Agreement:

I have spoken to the parent(s) of the above-named student(s) I am chaperoning to arrange the details of their child's care.required

I understand and confirm.

I understand that I am responsible for the care of the student(s) named above while they are under my supervision and that I am expected to chaperone them at any event in which they participate while under my care.required

I understand and agree.

I understand that the Delphian School requires that an adult (person over 21 years of age) drive students on and off the Delphian School campus.required

I understand and agree.

I understand that to chaperone the above-named student(s) from campus, I am also responsible for ensuring that the parent or legal guardian(s) has filled out and submitted a Campus Leave Form to the school, granting me the right to assume responsibility for chaperoning their child. required

I understand and agree.

I also understand that the school will not allow the student(s) to depart the campus under my care without both this Chaperone Agreement Form and the Campus Leave Form having been received by the school.required

I understand and agree.

I hereby indemnify and hold harmless Delphi Schools, Inc., the Delphian School, its employees, agents, students, and volunteers from all liability for any and all claims, including those of all other persons, as a result of chaperoning the above-mentioned student(s) on or off-campus with me.required

I understand and agree.

By submitting this form, I, the chaperone, assume responsibility for the student(s) named above, authorize this to serve as my digital signature, and agree to the terms set out in this form.required

I understand and agree.