Boiling Springs High School

Sponsors:

Activity:

Starting Date:   Ending Date:

 I agree to serve as a chaperon on behalf of Spartanburg County School District Two for the above-described activity.  I understand that throughout this entire activity I will be serving as a chaperon, supervising and controlling such activity, and acting in an official capacity for Spartanburg County School District Two as its authorized agent until its conclusion.

Signed this _______________day of____________________, 20__________

Print Name of Chaperon:

Signature of Chaperon:_____________________________________________________

Social Security Number: (Required for insurance purposes)

Form 3