Chaperone Application

Staff Questions

As a staff member applying to chaperone this trip as a volunteer, have your reviewed the “Holding Other Volunteer Positions” section of the employee handbook found on pages 19-20?*

Yes No

STOP

You must review the “Holding Other Volunteer Positions” section of the employee handbook prior to continuing this application.

Have you have informed your supervisor and HR of this volunteer role application?*

Yes No

STOP

You must inform your supervisor and HR prior to continuing this application. Please complete this step and return to the application once you have discussed with your supervisor and HR.

Do you understand that you will be required to use PTO and pay the chaperone fee listed above if selected to chaperone this trip?*

Yes No

STOP

Staff members chaperoning a council trip is required to use PTO and pay the chaperone fee. If you are not able to do so, please contact the lead for the trip to discuss prior to continuing the application.

Do you understand that you will be required to sign a Staff and Volunteer Agreement Form to keep on file with Human Resources if selected to chaperone this trip?*

Yes No

STOP

Signing a Staff and Volunteer Agreement Form is a requirement to be able to chaperone this trip.

Trip Specific Questions

Please rate your skill level for the following attributes on a scale of 1-5 with 1 being not skilled and 5 being highly skilled*

Please rate your skill level for the following attributes on a scale of 1-5 with 1 being not skilled and 5 being highly skilled
	1	2	3	4	5
Traveling by plane	Please rate your skill level for the following attributes on a scale of 1-5 with 1 being not skilled and 5 being highly skilled: Traveling by plane (1)	Traveling by plane (2)	Traveling by plane (3)	Traveling by plane (4)	Traveling by plane (5)
Navigating large metropolitan areas	Navigating large metropolitan areas (1)	Navigating large metropolitan areas (2)	Navigating large metropolitan areas (3)	Navigating large metropolitan areas (4)	Navigating large metropolitan areas (5)
Navigating public transportation	Navigating public transportation (1)	Navigating public transportation (2)	Navigating public transportation (3)	Navigating public transportation (4)	Navigating public transportation (5)
Leadership and decision making	Leadership and decision making (1)	Leadership and decision making (2)	Leadership and decision making (3)	Leadership and decision making (4)	Leadership and decision making (5)
Leading groups in unknown environments	Leading groups in unknown environments (1)	Leading groups in unknown environments (2)	Leading groups in unknown environments (3)	Leading groups in unknown environments (4)	Leading groups in unknown environments (5)
Conflict resolution	Conflict resolution (1)	Conflict resolution (2)	Conflict resolution (3)	Conflict resolution (4)	Conflict resolution (5)
Getting along with others	Getting along with others (1)	Getting along with others (2)	Getting along with others (3)	Getting along with others (4)	Getting along with others (5)
Cultural awareness	Cultural awareness (1)	Cultural awareness (2)	Cultural awareness (3)	Cultural awareness (4)	Cultural awareness (5)
Maintaining professionalism during extended travel	Maintaining professionalism during extended travel (1)	Maintaining professionalism during extended travel (2)	Maintaining professionalism during extended travel (3)	Maintaining professionalism during extended travel (4)	Maintaining professionalism during extended travel (5)
Working with high school age youth	Working with high school age youth (1)	Working with high school age youth (2)	Working with high school age youth (3)	Working with high school age youth (4)	Working with high school age youth (5)

Please rate your skill level for the following attributes on a scale of 1-5 with 1 being not skilled and 5 being highly skilled*

Please rate your skill level for the following attributes on a scale of 1-5 with 1 being not skilled and 5 being highly skilled
	1	2	3	4	5
Traveling by plane	Please rate your skill level for the following attributes on a scale of 1-5 with 1 being not skilled and 5 being highly skilled: Traveling by plane (1)	Traveling by plane (2)	Traveling by plane (3)	Traveling by plane (4)	Traveling by plane (5)
Navigating public transportation	Navigating public transportation (1)	Navigating public transportation (2)	Navigating public transportation (3)	Navigating public transportation (4)	Navigating public transportation (5)
Leadership and decision making	Leadership and decision making (1)	Leadership and decision making (2)	Leadership and decision making (3)	Leadership and decision making (4)	Leadership and decision making (5)
Leading groups in unknown environments	Leading groups in unknown environments (1)	Leading groups in unknown environments (2)	Leading groups in unknown environments (3)	Leading groups in unknown environments (4)	Leading groups in unknown environments (5)
Conflict resolution	Conflict resolution (1)	Conflict resolution (2)	Conflict resolution (3)	Conflict resolution (4)	Conflict resolution (5)
Getting along with others	Getting along with others (1)	Getting along with others (2)	Getting along with others (3)	Getting along with others (4)	Getting along with others (5)
Cultural awareness	Cultural awareness (1)	Cultural awareness (2)	Cultural awareness (3)	Cultural awareness (4)	Cultural awareness (5)
Maintaining professionalism during extended travel	Maintaining professionalism during extended travel (1)	Maintaining professionalism during extended travel (2)	Maintaining professionalism during extended travel (3)	Maintaining professionalism during extended travel (4)	Maintaining professionalism during extended travel (5)
Spending extended time outdoors	Spending extended time outdoors (1)	Spending extended time outdoors (2)	Spending extended time outdoors (3)	Spending extended time outdoors (4)	Spending extended time outdoors (5)
Working with high school age youth	Working with high school age youth (1)	Working with high school age youth (2)	Working with high school age youth (3)	Working with high school age youth (4)	Working with high school age youth (5)
Walking 5 miles/day in hot temperatures	Walking 5 miles/day in hot temperatures (1)	Walking 5 miles/day in hot temperatures (2)	Walking 5 miles/day in hot temperatures (3)	Walking 5 miles/day in hot temperatures (4)	Walking 5 miles/day in hot temperatures (5)
Problem solving	Problem solving (1)	Problem solving (2)	Problem solving (3)	Problem solving (4)	Problem solving (5)
Teamwork	Teamwork (1)	Teamwork (2)	Teamwork (3)	Teamwork (4)	Teamwork (5)
Sleeping in unknown environments	Sleeping in unknown environments (1)	Sleeping in unknown environments (2)	Sleeping in unknown environments (3)	Sleeping in unknown environments (4)	Sleeping in unknown environments (5)
Sharing sleeping areas	Sharing sleeping areas (1)	Sharing sleeping areas (2)	Sharing sleeping areas (3)	Sharing sleeping areas (4)	Sharing sleeping areas (5)
Staying calm when frustrated or exhausted	Staying calm when frustrated or exhausted (1)	Staying calm when frustrated or exhausted (2)	Staying calm when frustrated or exhausted (3)	Staying calm when frustrated or exhausted (4)	Staying calm when frustrated or exhausted (5)

What time of day is your most productive, creative, or energetic? Are you an early riser or a night owl? Tell us more.*

Do you consider yourself to be someone who plans every detail of an outing or are you more of a go-with-the-flow type? Tell us more.*

What languages do you speak other than English?*

Have you taken a Youth Mental Health First Aid class – or would you consider completing this before the trip? This is *NOT* required to be a chaperone.*

Yes, I have taken a Youth Mental Health First Aid class No, I have not taken a Youth Mental Health First Aid class but would consider taking one No, I have not taken a Youth Mental Health First Aid class

Please describe your Harry Potter skills/passion and how that will be beneficial to you being a chaperone for this trip.*

Tell us about any fears or concerns you have about elevation, wildlife encounters, insects, heights, tent accommodations, driving a 12-passenger vehicle (in the daylight or the dark), and anything else you may encounter on a high-adventure trip like this.*

What experience do you have that relate to the activities planned for the Colorado trip: whitewater rafting, camping and recreating more than 30 minutes away from emergency medical services for more than 36 hours, hiking 5-7 miles, not showering for more than 48 hours, etc.?*

What is your comfort level with water activities, including swimming, rafting, standup paddleboarding, etc.? How would you describe your own swimming skills?*

Tell us about your familiarity with Colorado. Have you lived there or traveled there before?*

Tell us about any experiences with altitude sickness or high elevation experiences.*

Tell us about your favorite multi-day outdoor experience.*

Do you have photography skills?*

Emergency Contact Information

Name:*

First Name

Last Name

Relationship:*

Email Address:*

Phone Number:*

Address:*

Address Line 1

Address Line 2

City

State

ZIP Code

Short Answer Questions

Briefly describe any skills you have that would be beneficial to the trip that you are applying to chaperone that were not listed in the skills inventory.*

Briefly describe any experience you have dealing with emergency situations. What was your role? How did you handle the situation? What was the final resolution?*

Briefly describe your experiences with Girl Scouts from different social, racial, cultural, religious, special needs, and economic backgrounds.*

References: List 2 references that are not related to you who can best speak about your ability to chaperone a GSCTX council sponsored trip.

Reference 1 Name:*

First Name

Last Name

Relationship:*

Phone Number:*

Email Address:*

Reference 2 Name:*

First Name

Last Name

Relationship:*

Phone Number:*

Email Address:*

Staff Questions

Trip Specific Questions

Emergency Contact Information

Short Answer Questions

References: List 2 references that are not related to you who can best speak about your ability to chaperone a GSCTX council sponsored trip.

Certification Inventory