Relay For Life of Berkeley Heights, Mountainside, New Providence & Summit
Youth Participation Agreement
The American Cancer Society Relay For Life requires one chaperone, 25 and older for every
ten youth team members. For this event, a youth is considered anyone 18 and younger.   
In addition to completing and turning in this agreement.  The youth participant must also complete an event registration form (either online or a scannable form). 

Name	 Birthdate 	
Address	
City	 State 	 ZIP	
Home Phone (	)	 Parent Email 	
Cell Phone (	)	
Team Name	Team Captain’s Name	
Chaperone’s Name _______________________________Chaperone’s Email_________________________________
Chaperone’s Phone Number (	)	 Chaperone’s Cell Phone (	)	
In the event of an emergency, it might be necessary to reach a parent or guardian. Please print his or her name and phone number on the line below.
Parent’s Name	Parent’s Home Phone (	)	
Parent’s Cell Phone (	)	Parent’s Email Address: ___________________________________
Welcome to the American Cancer Society Relay For Life! We hope you’ll have a great time as you raise money and help fight cancer. The American Cancer Society goal is to provide a safe, fun, and positive experience for all Relay participants. As a youth participant, you play a valuable role in attaining this goal. Please read through this participation agreement.

While participating, Relay For Life participants shall:
•	Respect the individual rights, safety, and property of others
•	Avoid displays of overly affectionate behavior•
•	Not participate in obscene and/or discriminatory language or roughhousing
•	Not be insubordinate to chaperones or the leader in charge of the event
•	Not possess or use weapons, alcoholic beverages, tobacco and/ or illegal drugs at any event, activity, or meeting, or remain in the presence of individuals who possess or use these items
•	Abide by all rules of the attended event, activity, or meeting
•	Participate in activities to the best of his or her ability
•	Notify a chaperone or staff person if he/she has concerns or medical needs during the Relay For Life event.
•	Not engage in conversations or activities that are sexual in nature
•	Not leave the event site(s) without permission from the chaperone, parent/guardian, and Event Chair
•	Pay any costs related to damage or destruction of property that he or she incurs, including any property damage to other Relay For Life participants or to third parties. Such costs will be charged to the youth participant and/or their parent(s)
Disciplinary action
Penalties and/or disciplinary action for infractions of this code of conduct may include any or all of the following:
•	Sending youth home
•	Barring that member from future American Cancer Society activities
•	Being held responsible for the cost of damages and repairs in the event of damage/destruction of property
•	Releasing the member to the nearest law enforcement agency and/or the proper authorities for significant violations of state law
Team chaperones will notify parents of any actions taken.

Waiver of Liability: I assume all risk of personal injury including death and damage to personal property that may be sustained by my child while attending and/or participating in this event. I release the American Cancer Society, including any unit or Division thereof, from any and all liability for any injury, death or damages that my child may suffer whether due to the negligence of the American Cancer Society, their respective agents, servants, employees or volunteers. I also agree to defend, indemnify and hold harmless the American Cancer Society and its directors, officers, employees and volunteers from and against any and all actions, suits, claims, demands, causes of action, proceedings, losses, costs and expenses including and without limitation all attorney fees and disbursements, damages, liability and fines or penalties in any way arising out of, or relating to, or connected with directly or indirectly, my child’s participation in this event regardless of whether there is active or passive negligence or fault on the part of the American Cancer Society or other released parties.

•	I give permission for my son/daughter to participate in the American Cancer Society Relay For Life and my son/daughter has completed and turned in the event registration form.
•	I give permission for my son/daughter to serve on the Relay For Life planning committee.

Parent’s Signature (required)_____________________________________________	 Date ______________________	
By my signature below, I acknowledge receipt of this document and acknowledge that I have read and agree to abide by the guidelines in this document. I am aware that if I violate the agreement, the staff may, at their sole discretion, terminate my participation, and my parent/guardian will be contacted and required to provide me with transportation home at my own expense. Additionally, I understand that the American Cancer Society works with partner organizations and at its discretion 
may report any disciplinary action to partner organizations.

Youth Participant’s Signature: _______________________________________________     Date  _____________________
	Relay For Life of Berkeley Heights, New Providence & Summit
Chaperone Agreement
The American Cancer Society Relay For Life requires one chaperone older than 25 
for every ten youth team members.  (For this event, a youth is considered anyone 
18 and younger.)  Please return completed form at Bank Night or prior.

 

Name	
Address	
City, State, ZIP	
Phone (	)	
Email	
Cell Phone (	)	
Team Name	
Team Captain’s Name	
Number of students on your team age 18 and younger (must be ten or fewer students)	
Do you have completed youth forms for all youth on your team?	

The following guidelines are designed to help volunteers understand their responsibilities while performing within
the scope of an American Cancer Society chaperone position. Chaperones are expected to abide by all American Cancer Society policies. As an adult participant, you play a valuable role in providing a safe, fun, and positive experience. Please read through this agreement and sign below.
Adult chaperone is required to:

1.	Respect the individual rights, safety, and property of others and not use obscene or discriminatory language
2.	Not discriminate in any policies, procedures, or practices on the basis of race, religion, color, national origin, sex, gender, marital status, sexual orientation, age, veteran status, medical condition, or disability
3.	Have a valid driver’s license and carry proof of automobile liability insurance if the volunteer leader is to use a motor vehicle to transport self or others. Also, ensure that all passengers use seatbelts
4.	Not possess or use alcohol and/or illegal drugs (or be under the influence thereof) while involved in any American Cancer Society event, meeting, or activity
5.	Make all reasonable efforts to supervise the team, account for members’ whereabouts, and not leave the site
6.	Not allow any youth to leave the event premises unless authorized by the youth’s parent/guardian and notifying the Society staff partner and Event Chair
7.	Complete and keep on person the Youth Emergency Contact List
8.	Represent the American Cancer Society to youth and adults by conducting themselves courteously in manner and language, exhibiting good sportsmanship, serving as a positive role model, and demonstrating reasonable conflict resolution skills
9.	Abide by all applicable laws plus American Cancer Society policies and guidelines. This includes, but is not limited to, child abuse, fiscal management procedures, and substance abuse
10.	Accept supervision and support from salaried staff or designated management volunteers
11.	Accept the responsibility to promote and support the vision, mission, and values of the American Cancer Society
12.	Ensure that youth team members follow ground rules and participate in Relay For Life activities
13.	Participate in activities to the best of his or her ability, as well as attend at least one Relay For Life team captain meeting or chaperone meeting
14. Appreciate the valuable role that youth play in the American Cancer Society

Chaperones will be notified of any violations of the ground rules itemized on the Youth Participation Agreement. If
the problem persists, the youth team member will be asked to leave the premises for the remainder of the event. In some cases, this may necessitate the chaperone calling the emergency contact person.

I have read this document, I understand its contents, and I agree to its terms. I also understand that if I do not follow the above guidelines, my participation in this American Cancer Society activity will be terminated.

Relay For Life of Berkeley Heights, New Providence & Summit
Youth Emergency Contact List for Chaperone
Chaperones please be sure to collect all the necessary information for each participant on your team.  
Please keep this list with you during the event in case of any emergencies, it will be very helpful to have the emergency information for the students you are chaperoning.  Thank you!	

1.)	Youth Name	
Cell Phone Number (	)	
Parent/Guardian Home Phone (	)	Parent/Guardian Cell Phone (	)	
Student turned in Registration Form?	
Student turned in Youth Agreement Form?	
2.)	Youth Name	
Cell Phone Number (	)	
Parent/Guardian Home Phone (	)	Parent/Guardian Cell Phone (	)	
Student turned in Registration Form?	
Student turned in Youth Agreement Form?	
3.)	Youth Name	
Cell Phone Number (	)	
Parent/Guardian Home Phone (	)	Parent/Guardian Cell Phone (	   )	
Student turned in Registration Form?	
Student turned in Youth Agreement Form?	
4.)	Youth Name	
Cell Phone Number (	)	
Parent/Guardian Home Phone (	)	Parent/Guardian Cell Phone (	   )	
Student turned in Registration Form?	
Student turned in Youth Agreement Form?	

5.)	Youth Name __________________________________________________________________________________________

Cell Phone Number (	)	
Parent/Guardian Home Phone (	)	Parent/Guardian Cell Phone (	   )	
Student turned in Registration Form? 	
Student turned in Youth Agreement Form?	

	
Relay For Life of Berkeley Heights, New Providence & Summit
Youth Emergency Contact List for Chaperone
Chaperones please be sure to collect all the necessary information for each participant on your team.  
Please keep this list with you during the event in case of any emergencies, it will be very helpful to have the emergency information for the students you are chaperoning.  Thank you!	

6.)	Youth Name	
Cell Phone Number (	)	
Parent/Guardian Home Phone (	)	Parent/Guardian Cell Phone (	)	
Student turned in Registration Form?	
Student turned in Youth Agreement Form?	
7.)	Youth Name	
Cell Phone Number (	)	
Parent/Guardian Home Phone (	)	Parent/Guardian Cell Phone (	)	
Student turned in Registration Form?	
Student turned in Youth Agreement Form?	
8.)	Youth Name	
Cell Phone Number (	)	
Parent/Guardian Home Phone (	)	Parent/Guardian Cell Phone (	   )	
Student turned in Registration Form?	
Student turned in Youth Agreement Form?	
9.)	Youth Name	
Cell Phone Number (	)	
Parent/Guardian Home Phone (	)	Parent/Guardian Cell Phone (	   )	
Student turned in Registration Form?	
Student turned in Youth Agreement Form?	

10.)	Youth Name _________________________________________________________________________________________

Cell Phone Number (	)	
Parent/Guardian Home Phone (	)	Parent/Guardian Cell Phone (	   )	
Student turned in Registration Form? 	
Student turned in Youth Agreement Form?