Central Scheduling

Policy 150 Statement of Acknowledgement Waiver

Chaperone Acknowledgement Form
As an individual bringing minors on campus at Dixie State University, you are required to comply with DSU Policy 150 (Minors
and Vulnerable Adults on Campus). Below is required information about these policies:

Policy 150

I will commit to strictly following the rules and guidelines in this Statement of Acknowledgement as a condition of overseeing or
chaperoning minors (children and youth) and vulnerable adults, who are participating in Dixie State University (“University”)
campus programs and/or activities.
I will:

  • Treat everyone with respect, patience, integrity, courtesy, dignity, and consideration.
  • Never be alone with minors at university activities without another authorized adult (as defined in DSU Policy 150*) present,
    unless in a very limited or official capacity, in open public areas and/or designated areas.
  • Use positive reinforcement rather than criticism or comparison when working with children and/or youth.
  • Maintain appropriate physical boundaries at all times and touch children only when necessary and in ways that are
    appropriate, public, and non‐sexual.
  • Comply with the mandatory reporting regulations found in DSU Policy 150, including reporting any suspected abuse of a
    minor or vulnerable adult. I understand that failure to report suspected abuse to the University’s Public Safety Office or state
    authorities is against the Utah Mandatory Reporting Requirements Regarding Children (see Utah Division of Child and Family
    Services).
  • Watch the Minors on Campus Training found on the Event Services & Risk Management website.
  • Cooperate fully in any investigation of abuse of a minor or vulnerable adult.

I will not:

  • Have one‐on‐one contact with minors or vulnerable adults.
  • Allow any inappropriate touching, including between minors or vulnerable adults.
  • Have any direct electronic contact with minors without another authorized adult being included in the communication, except as noted in section 6.3.1 of DSU Policy 15
  • Engage in abusive conduct of any kind toward, or in the presence of, a minor or vulnerable adult.
  • Strike, hit, administer corporal punishment to, or touch in an inappropriate or illegal manner any minor or vulnerable adult.
  • Pick up or drop off minors at their homes, other than the driver’s child(ren), except as specifically authorized in writing by the minor’s parent or legal guardian and in the company of another authorized adult, as defined in DSU Policy 150*.
  • Engage in abusive conduct or sexually provocative games, including hazing or any activity involving harassment, abuse or humiliation.
  • Swear or use other inappropriate language, use or respond to sexual innuendo, or make sexually suggestive comments.
  • Use or provide alcohol or illegal drugs to any minor or vulnerable adult.
  • Use or provide prescription drugs or any medication to any minor or vulnerable adult unless specifically authorized in writing by the parent or legal guardian.
  • Make sexual material in any form, including printed and electronic, available to minors participating in programs or activities, or assist a minor in any way in gaining access to such materials.
  • Shower, bathe, or undress with, or in the presence of, minors or vulnerable adults.

I understand that any action inconsistent with this policy or failure to act (as mandated by DSU Policy 150) may result in my
removal from the University, trespassed from having future events on Dixie State University’s campus, and/or other actions as
covered by law. My signature confirms that I have read this Statement of Acknowledgement, watched the required training, and
that as a person working with minors or vulnerable adults, I agree to follow these standards and other related policies of the
University.

*Authorized adult is defined as individuals, 18 years of age or older, paid or unpaid, who interact with, supervise, chaperone, or otherwise oversee minors or vulnerable adults in university‐sponsored or co‐sponsored programs/activities or on‐campus activities sponsored by outside organizations.
Includes faculty, staff, volunteers, students, interns, contractors, or on‐campus vendors.
Receipt sent to Responsible Party (Professor, Coach, Club Leader) *