Spirit of America – Chaperone Chaperone Registration "*" indicates required fields 1Applicant2Medical History3Insurance Waiver4Chaperone Responsibilities Product ID is required. Please check the referring link. If you need assistance, please contact us. Freedoms Foundation Application Page for From To Participant InformationName* First Last Date of Birth* MM slash DD slash YYYY Gender* Male Female Email* Home Phone*Cell PhoneHome Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Postal Code Participant Medical InformationHeight Weight Most recent exam MM slash DD slash YYYY Most recent tetanus toxoid immunization MM slash DD slash YYYY Most recent COVID-19 vaccination MM slash DD slash YYYY Upload COVID-19 Vaccination CardMax. file size: 2 MB.Please provide any information about a student’s health history that may impact their participation in the program. This may include health concerns, food and medication allergies (see below), and/or current medications (see below).ConditionsNoneBleeding/Clotting disordersConvulsionsDiabetesFrequent ear infectionsHeart defect/diseaseHepatitisHypertensionMononucleosisAllergiesNoneAsthmaHay FeverInsect StingsIvy poisoning, etc.Other DrugsPenicillinImmunizationsNoneChicken PoxMeaslesMumpsRubellaDTaPFood AllergiesCurrent Medication TakingMedication AllergiesList any condition or illness that Freedoms Foundation should be aware of that is not mentionedDoctor's InformationDoctor's Name* Doctor's Phone*Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Postal Code SignatureSignature Insurance Waiver*Freedoms Foundation does not carry medical insurance to cover participants. All participants should be covered by personal or family insurance. We (I) hereby certify, under penalty of perjury, that the above named is covered by medical insurance. I agree to the Insurance WaiverSignature*Insurance Company Policy/Group number Expiration Date of Insurance MM slash DD slash YYYY Insurance CardMax. file size: 2 MB.Either upload a copy of insurance card here or bring a copy with you to the program.Please list emergency number(s) other than those above at which parent, guardian, or another relative may be reached during the conference.Name PhoneName Phone As an adult chaperone you have an extremely important role to play throughout the weekend. Adult chaperones can add to the overall success of a given program, or make it a negative experience. It is important for all chaperones to know that they are expected to participate in the entire conference, which is a demanding challenge. They should be well rested and in good health. There is no time to take trips to places of individual interest, or visit friends or relatives. Before Conference Complete Armatus online training courses on preventing child abuse through Freedoms Foundation at Valley Forge. Get to know the students you will accompanying. Understand the students’ needs; allergies, medications, etc. Familiarize yourself with the travel arrangements and keep track of your charges. Reinforce the Honor Code which the students signed prior to arrival. (The Program director will reinforce same code.) During Conference Be familiar with the rules governing the conference activity as declared by program staff. Introduce yourself to all Foundation Staff Members involved with the program as soon as possible upon arrival. There will be a meeting with adults during student ice breakers on Thursday night. Remain on campus and occupy quarters in the residence halls during the entire length of the conference. Participate in all activities to the fullest extent possible and ensure that your students do the same. Help to maintain order in classroom, dining room, airport and elsewhere as required. Draw the attention of staff to all unusual occurrences, unacceptable behavior or personal problems that may affect the session. Assist in taking attendance of your students, thus insuring that everyone participates in scheduled program activities. Keep to the approved schedule and be on time. Make this weekend alcohol and drug free HAVE FUN! Freedoms Foundation places a great value on the help and support of adult chaperones. We look forward to having you participate in the conference. It is a unique opportunity to share with young people your appreciation for the freedoms we enjoy as Americans and help them understand the responsibilities of citizenship.Signature*EmailThis field is for validation purposes and should be left unchanged.
