LOS ANGELES UNIFIED SCHOOL DISTRICT

JOHN DEASY, PH.D. SUPERINTENDENT OF SCHOOLS

EDUCATIONAL SERVICE CENTER NORTH

LANAI ROAD SCHOOL

LINDA DEL CUETO Superintendent District 1

4241 Lanai Road Encino, California 91436 Telephone 818-788-1590 Fax 818-788-4263

Heather Ann Jeanne Principal

Tracy Sandler Asst. Principal, Elem. Instructional Specialist

Field Trip Chaperone Agreement Your role as a chaperone is an important one, and while enjoyable, requires that you agree to certain responsibilities. A chaperone must….. 1. Be a parent/ guardian of a child in the class taking the field trip, and over 18 years of age. 2. Come alone; no siblings permitted on field trips. 3. Have a volunteer application and negative TB test results on file with the school. 4. Be willing and physically able to participate in all activities. 5. Be able to communicate clearly with the children. You must…. 1. Arrive on time and bring a watch. 2. Dress appropriately for the activity. 3. Know the children in your group: Name tags and/or a list of students' will be supplied by the teacher. 4. Watch children carefully and be alert at all times. 5. Be alert to potential dangers- strangers, busy streets, etc. Do not take chances. Periodically take a head count of your students. 6. Never leave children alone or unescorted, for even a moment; if you have both boys and girls in your group pair up with an opposite sex chaperone, same sex adult should escort one group to the restroom while the other chaperone waits outside with the other group. Do not send children off from the group in pairs to go to the restroom. 7. Do not purchase souvenirs or gifts for the children, not even for your child. 8. Turn off your phones. No personal calls, texting or emailing unrelated to the field trip. 9. Know the safety rules: o Should the bus have seatbelts, children are required to use the seatbelt. Two children cannot share one seat belt; each child must have a working seatbelt. If you are unfamiliar with how the seat belts work, ask the bus driver for instructions. Please ensure each child is buckled in properly. o Do not release students to anyone other than the teacher, not even the child’s parents. o Do not administer ANY medications to a youngster.

IN THE EVENT OF AN EMERGENCY The supervising teacher, or a designed volunteer, will be responsible for the first aid kit. Report all illnesses and injuries to the teacher. In the case of my personal illness or injury, please contact: __________________________________ Print Name: First and Last

________________ Relationship

_____________________________ Phone Number(s)

I have read and will adhere to the requirements stated above: __________________________________

Print Name: First and Last

________________________________ Mobile Phone Number

__________________________

Signature

___________

Date

_________________________________ Child’s Name

field-trip-chaperone-form-2012.pdf

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