APPENDIX E
I, ____________________________, the undersigned, understand that my role as an Approved Chaperon requires utmost responsibility on my part to ensure the safety and protection of children that may come in contact with ______________________________.
Due to the knowledge I gained through participating in the Chaperon Training class, I am aware that there are several rules that I must follow in order to ensure the safety of children. These rules will be adhered to. These rules include the following:
1. I may never leave any child alone with an offender. I understand that this means not even for short durations. When I leave the room the offender will also leave the room, and not return until after I return, even if I leave for only a brief time period.
2. I agree to not allow any child who has been victimized by an offender to have contact the offender, unless permission has been granted by the child’s therapist, the offender’s therapist, as well as the Probation / Parole department.
3. I understand that all physical contact is to be initiated by the child ONLY! No adult is to suggest physical contact, including myself.
4. The offender will never be responsible for babysitting or supervising children.
5. I understand that it is inappropriate for the offender to initiate/discuss issues related to sexuality or dating with any children.
6. The offender will not tickle or wrestle with a child. No tickling or wrestling is permitted between offender and children.
7. I understand that it is inappropriate for children to be around the offender if the child is not dressed. All needed physical hygiene assistance will be provided by me, as is age-appropriate for the child. All adults & children will be fully dressed at all times.
8. I understand that the offender may never go into the child’s bedroom.
9. I will not let a child sit next to the offender in the car, restaurant, church, etc., if I cannot maintain visual contact at all times.
10. The offender will not have secrets of any kind with any child.
11. I understand that I cannot allow a child to enter the offender’s bedroom or the bathroom if he/she is occupying it.
12. I understand that all bathroom doors are to be equipped with locks. If the offender is residing in the home, all bedroom doors are to be equipped with locks.
13. The offender will not be primarily responsible for discipline of the child.
14. I will address any persistent concerns I have about the offender’s behavior with his/her therapist.
15. I agree to not be under the influence of ANY drug/alcohol while I am acting as a chaperon.
16. There will be no pornography (magazine, book, videos) in the home or other areas where the offender is in the presence of a child.
17. I understand that I am not responsible for the offender’s behavior. I can only be responsible for protection of children.
18. I agree to notify the appropriate authorities, (i.e. police, Department of /Children and Youth Services, etc.) if a child discloses being abused or if I suspect it.
19. I understand that if I do not abide by the above responsibilities and rules, I will be deemed inappropriate to continue as an Approved Chaperon, at which time I will lose my status to provide supervision.
20. I agree to hold no secrets between the offender and myself. I will report any “secret” communications between myself and the offender to the treatment therapists or the authorities.
Any changes to this contract must be made in writing and signed by the offender’s therapist, Probation department and other relevant treatment providers.
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Signature Date
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Witness Signature Date