Chaperone Application

33%

Full Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone*
Cell Phone
Email*
Date of Birth
Date Format: MM slash DD slash YYYY

The applicant(s) must be at least 25 years of age at time of travel. (Date of Birth is optional)
Employment Information
Current Employer
Your Current Position/Title
Date of Employment
School Name (If applicable)
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Contact Name
First Last
Contact Phone
Previous Employer
Your Previous Position/Title
Date of Employment
School Name (If applicable)
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Contact Name
First Last
Contact Phone
Emergency Contact Information
Please list an emergency contact for the time you would be abroad.
Emergency Contact Name*
First Last
Relationship
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone*
Cell Phone

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Please respond to the following questions. At least two of the responses should be answered in Spanish
Describe your ability to communicate in Spanish, including your confidence level to handle emergency situations and your OPI rating if you have one.*
What experience have you had in leading groups of high school students?
Describe experiences you have had with other cultures.
Do you have previous experience as a travel group leader? If so, please use someone familiar with this experience as a reference.
Describe any experiences you have had living or traveling abroad. Have you helped prepare students to live or travel abroad? If yes, include this experience in your response.
Write a short paragraph describing your reasons for wishing to accompany our student group as a chaperone to Costa Rica?
What particular qualities do you feel you can bring to the Program as a chaperone?
Please explain any obligations or responsibilities here in Oregon that during the 8-week travel period could impact your ability to carry out the responsibilities as "outlined on the "chaperone responsibilities" tab of the website.

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References
Provide names of three people who know you well. Please provide their name, address, phone number, and email address so that we can contact them regarding your application. One should be a professional reference, one personal, and one of your choice.
Professional Reference*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone Number*
Email*
Personal Reference*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone Number*
Email*
Your Choice - Reference*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone Number*
Email*
Attach a Current Photo*
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Employment Information