Fillable Underage Chaperone Agreement (Rogue Community College)

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Underage Chaperone Agreement (Rogue Community College)

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Underage Student Chaperone Agreement
Chaperone Name:
Relationship to Student:
Chaperone address and phone #:
City/State/ZIP:
Phone #:
Student Name:
Phone #:
RCC Student ID #:
Term(s):
Academic Year:
Course Number:
Title:
Start Date:
End Date:
Days in Course: Mon Tues Wed Thurs Fri Sat Sun
Brief Description of Duties: (eg., Transportation to and from the field trip site; supervision when
the course is not in session; other.)
RCC Instructor Name:
It is the intent of Rogue Community College (RCC) to provide a safe environment for all
students. Underage students require chaperones on overnight field trips or day trips when the
underage student must travel on his/her own. Only parents or legal guardians qualify as
chaperones. The purpose of this Waiver Agreement is to authorize the chaperone to be on an
RCC campus to attend a field trip orientation and to accompany students younger than 18 year
old on day long or overnight field trips. If for any reason, a chaperone is unable to attend a field
trip with the underage student, the student will be ineligible to join the trip and will receive a full
refund of tuition and fees.
This Waiver Agreement must be completed by all chaperones. The form will be initiated by the
field trip instructor at the orientation and signed by the chaperone at the orientation. The
instructor will send the forms to Rogue Central.
Student Chaperones must agree to the following terms and conditions:
Chaperone agrees that he/she is not an employee, volunteer, or agent of RCC, and is not
affiliated with RCC in any way.
Chaperone agrees that the College accepts no responsibility for the actions of the
Chaperone, and agrees to hold RCC, its organization, officers, employees,
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representatives, agents and assignees harmless in the event of loss, damage,
destruction or injury to person or property as a result of activities engaged in under this
contract except that arise out of the sole negligence of RCC.
Chaperone agrees that RCC is not responsible for loss or theft of personal property.
Chaperone responsibilities do not end when formal instruction is complete. Chaperones
attend courses designated by RCC as having extended supervisory needs and it is the
duty of the Chaperone to ensure appropriate, ethical and safe behaviors of the underage
student for the duration of the field trip.
Chaperone agrees to adhere to all College policies, procedures, and codes of conduct
and maintain an orderly, safe, and professional learning environment.
Chaperone agrees that his/her role is to supervise and have custody of the student
before and after the instruction portion of the field trip, is not to interfere or help the
student academically, and shall remain neutral in a testing environment.
Chaperone agrees that the field trip instructor has the sole authority to direct the actions
of the underage student during class sessions and will not interfere with or contradict the
instructor’s direction.
Chaperone will comply with the Family Education Rights and Privacy Act (FERPA) and
agree to confidentiality agreement below.
Chaperone Confidentiality Agreement
I understand that as a chaperone (parent, or legal guardian), I must sign an underage
release form.
I understand that by virtue of my presence on a Rogue Community College field trip, I
may have access to records that contain individually identifiable information, the
disclosure of which is prohibited by the Family Educational Rights and Privacy Act of
1974.
I agree to maintain the confidentiality of all information with which I come into contact as
a chaperone at the college. I will not share information pertaining to student academic,
financial, or disciplinary actions with anyone other than current college staff/faculty who
have a legitimate need to know.
Authorization/Signatures
By signing below, the following agreements are made:
Chaperone is agreeing to the terms and conditions as listed above.
Student is agreeing that he/she understands the role of the chaperone and will comply with
College policies and procedures regarding the use of a chaperone.
RCC instructor is confirming approval of the student’s use of the chaperone.
Signature Printed Name Date
Chaperone
Student
Instructor
NOTE: AGREEMENT IS NOT VALID UNTIL ALL SIGNATURES ARE OBTAINED. RCC SIGNATURES MUST BE OBTAINED PRIOR TO CHAPERONE’S ATTENDING
RCC COURSES.
R
CC is an open institution and does not discriminate. For RCC's non-discrimination policy and a full list of regulatory specific contact
persons visit the following webpage: www.roguecc.edu/nondiscrimination.
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Underage Chaperone Agreement (Rogue Community College)

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Completed 26 July 2020

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