Chaperone Training Program

Thank you for your interest in becoming an approved chaperone. Please complete the information below.

Full Name:

Date of Birth:

Address:

City:

State:

ZIP:

Phone Number:

Email address

Relationship to Sponsee:

Have you ever been convicted of a felony?

Yes No

Do you understand and agree to follow all chaperone requirements?

Yes No

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature:

Date

For Office Use Only

Background Check Completed:

Yes No

Approved by LSOTP:

Yes No

Date of Approval:

Notes:

Your information will be encrypted.

Chaperone Training Program – Sign-Up Form