Chaperone Application

Legal Name (as it appears on driver's license)*
First Middle Last
Preferred Name
Please enter the name you like to be called.
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home/Work Phone
Cell Phone
Email*
Social Security
Date of Birth
Drivers License State & Number
Airport Group
- Seattle
- Portland
- Denver
Dates Available
Referred By
T-Shirt Size
Have you ever been accused or convicted of a crime?*
Have you ever been accused or convicted of mishandling or misappropriating funds?*

Save and Continue Later

Emergency Contact Information
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home/Work Phone
Cell Phone
Relationship

Save and Continue Later

Education and Experience
Education
School Dates Attended Major Course of Study Diploma/Degree
Other educational experience/special skills (ie: First Aid, CPR, sign language)
Describe experience working with people with developmental disabilities
Have you ever volunteered/worked for another special needs travel company or have you ever provided travel assistance services for people with intellectual & developmental disabilities through your job or personally? Please explain
Travel Experience
Volunteer Experience

Save and Continue Later

Employment History: Current/Latest Job
For these three pages, please enter information for your last three jobs. If you have held less than three jobs, please leave the fields blank for the jobs that you have not held.
Employer Name
Supervisor
Job Title
Brief Job Description
Start Date
End Date
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Reason for Leaving

Save and Continue Later

Employment History: 2nd Most Recent Job
For these three pages, please enter information for your last three jobs. If you have held less than three jobs, please leave the fields blank for the jobs that you have not held.
Employer Name
Supervisor
Job Title
Brief Job Description
Start Date
End Date
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Reason for Leaving

Save and Continue Later

Employment History: 3rd Most Recent Job
For these three pages, please enter information for your last three jobs. If you have held less than three jobs, please leave the fields blank for the jobs that you have not held.
Employer Name
Supervisor
Job Title
Brief Job Description
Start Date
End Date
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Reason for Leaving

Save and Continue Later

First Professional Reference
On these three pages, please list three people not related to you whom you have known for at least one year.
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Relationship
Phone

Save and Continue Later

Second Professional Reference
On these three pages, please list three people not related to you whom you have known for at least one year.
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Relationship

Save and Continue Later

Third Professional Reference
On these three pages, please list three people not related to you whom you have known for at least one year.
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Relationship

Save and Continue Later

I state that all of the information provided above is true and accurate to the best of my knowledge. I authorize investigation of all statements contained in this application. I understand that misrepresentation or omission of facts is a Federal crime punishable by law.
Today's Date
Your Name ("Signature")
Comments
This field is for validation purposes and should be left unchanged.

Save and Continue Later

Emergency Contact Information

School	Dates Attended	Major Course of Study	Diploma/Degree