Appendix D Sample Youth Chaperone Consent And Release Form printable pdf download

Appendix D

Sample Youth Chaperone

Consent and Release Form

USA Ultimate

Youth Chaperone Consent

and Release Form

V.3

I will chaperone for (Name of Organization/Team/Player):______________________________________

____________________________________________________________________________________

Org/Team/Player Location (City/State): ____________________________________________________

Applicant’s Name: ____________________________________________________________________

Applicant’s Home Address: ______________________________________________________________

Street

Apt.#

_____________________________________________________________

City

State

Zip Code

Home Phone: (______)_____________________

E-mail: ________________________________

Drivers License Number: _________________________________

State: _______________

________________________________________________, understand that I am

[Name of Applicant]

responsible for obtaining Medical Authorization forms for each of the minors on my team/that I am

chaperoning and having them available at USA Ultimate events.

Age Requirement

I understand that the age requirement for chaperones at USA Ultimate H.S. Easterns, USA Ultimate H.S.

Westerns and USA Ultimate Youth Club Championships (YCC) is 25 or older.

I understand that the age requirement for chaperones at all other USA Ultimate events (includes USA

Ultimate-sanctioned events, H.S. state championships, etc) is 18 or older AND have graduated from high

school.

I confirm that I was born on ________/________/_________



I confirm that I have graduated from high school.

Name (printed): ________________________________________

Date: ____________________

Signature: _________________________________________________________________________

All portions of this form must be completed or it will not be accepted – one form per chaperone.

Chaperone forms are valid for one calendar year, expiring on 12/31 of each year.

USA ULTIMATE

4730 Table Mesa Drive, Suite I-200C, Boulder CO 80305

Web:

Email:

Tel: 303-447-3472

Fax: 303-447-3483

USA Ultimate Resource Guide

101

Appendix D Sample Youth Chaperone Consent And Release Form

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