CRR (China Research Residency) Chaperone
I, ___________________________, agree to all of the requirements stated below.
I have no criminal record
I am not on any illegal/ controlled drugs, unless proscribed by my doctor.
I am not an alcoholic or compulsive gambler
I have no serious / terminal ailments
I am willing to put all children in my care before myself in any emergency
I am not pregnant
My job allows me to be gone for about 15 days in May
I am totally committed to this trip
I am over 20 years of age
I have a Green Card, current Passport (if I don't have one I will acquire one
ASAP), and Work Permit
I have current health insurance
Once/ If I am chosen as a chaperone for the 2007 CRR trip to china, I will follow
through with my decision, unless I cannot fulfill the other stated agreements.
By signing this contract, I am agreeing to all of the statements listed above. If I
cannot meet all of these requirements, I understand I will be disqualified from being a
Name: _______________________________________ Date: _____________
1. Do you have a child going on this trip?
2. If so how do you feel about him/her being under someone else's supervision?
3. Why do you want to attend this trip?
4. What do you feel makes you eligible to go on this trip?
5. What experience do you have with middle school / high school students?
6. Do you prefer to work independently? (1 is very independent, 5 likes to
work with others exclusively)
1 2 3 4 5
7. Do you speak Chinese?
8. How is your Chinese level? (1 is no Chinese, 5 is fluent)
1 2 3 4 5
9. Do you have a valid First Aid and CPR card?
10. What is your current job?
11. What current or previous jobs have you had that will help you in the position?
12. In what ways do you plan to let the kids have some freedom in their choices?
13. How do you envision yourself working with other chaperones?
14. What are your experience's abroad?
15. Do you have any health issues we should know about? (Allergies, asthma,
Chinese Research Residency
Chaperone Application Form
Chinese Immersion Program
Hosford Middle School
Please return this form to a member of the chaperone
committee (Caitlyn Vincent, Linnea Havener, Laura Lesowske) or
put it in Ms. Bee's office mailbox. It must be turned in before
3:45 pm on Friday Dec. 7th.
We are looking for chaperones that are willing to
accompany our group in China. You don't have to know
Chinese or much about the culture to be eligible.
The trip is tentatively set for May 8 th through May 23rd,
2008. The funding will cover up to $1,000 of your airplane
ticket. After that, you must cover the rest of the airplane
ticket and other expenses. Those expenses will range from
about $300 to $1,000.
We really look forward to a fun trip. Help make it happen!
Sincerely, Caitlyn Vincent, Laura Lesowske, and Linnea
Havener, Advisor – Sarah Pons, The 2008 RR Chaperone
APPLICATION FOR M - Complete the questions below.
During the week of the 17th we will schedule an interview when