Note: Do not use this sample form without customizing it for your institution and, if necessary, having the document reviewed by institutional legal counsel or higher administration to ensure consistency with local, state, and federal laws and institutional policy.
I, ____________________________________, understand that as a [name of camp or clinic] staff member I am responsible for maintaining a camp or clinic environment that is positive and safe for participants. I am expected to exercise good judgment at all times, adhere to my job description and all policies, and report any situation that could have a negative effect on a participant. As a supervisor of children or young adults, I realize that the following behaviors are essential.
- I must always keep my cell phone charged and with me, and I have the camp director’s number recorded in my contact list.
- If I see any strangers around the camp or clinic, I will notify the camp director immediately.
- I must keep track of all participants assigned to me from the time they arrive until the time they depart. If a participant goes missing, I must initiate the missing child protocol immediately.
- Except in the case of an emergency, I must never delegate my responsibilities to anyone else.
- I must always carry the first aid kit that has been provided to me and make sure that water is available at all activity sites.
- To prepare for an emergency, I must frequently conduct radio checks to assure accessibility to sports medicine staff.
- I must contact the sports medicine staff after any injury or bee sting, if a participant appears to be ill or emotionally unstable, or for any other circumstance that compromises a participant’s physical or mental health.
- I must continually assess each participant’s capabilities to take part in activities. If at any time I believe that continued participation creates a risk to the participant or another child, I must remove that participant from the activity and find a suitable alternative.
- My language and behavior must be professional and enthusiastic.
- I should demonstrate a good balance of positive and corrective feedback along with a patient and caring teaching style.
- I must treat all participants fairly and equally and ensure that everyone around me does the same.
- I must monitor participant behavior and demonstrate a no-tolerance policy for behavior that intimidates, isolates, or creates any hierarchy or class system among participants.
- If any participant creates ongoing problems, I must work with the camp director to determine whether he or she should be transferred to another group or be removed from camp.
- I must inspect equipment and facilities daily to assure their safety and report any real or potential hazards.
- If at any time I am unable to perform my duties, I must notify the camp director immediately so that a suitable replacement can be assigned.
- I must always demonstrate good sportsmanship and never place winning as a priority over participant enjoyment or learning.
By signing below, I am also attesting that during a staff training session conducted on [insert date], I was given copies of the following policy documents and all documents were reviewed by the camp director:
- Professional coach behavior
- Equipment safety
- Facility safety
- Missing child protocol
- Sports medicine policies
- Description of duties
- Official camp or clinic schedule
- Camp or clinic policies
- Expectations of participant behavior
- Residence hall policies (overnight camps only)
- Responsibility for participant experience and safety form
I was given the opportunity to ask for and receive clarification about any policies not understood. I agree to comply with these policies and understand that failure to comply with any of these policies may result in sanctions or immediate dismissal as a staff member. I also understand that these policies cannot address every possible situation that presents itself and they do not eliminate the expectation of good judgment and professional behavior on my part.
I understand that I am required to report any violation of these policies to the camp director whether committed by me or another member of the staff and that failure to report a violation may result in sanctions or dismissal as a staff member.
Staff member: ____________________________________
Lopiano, D. and Zotos, C. (2013) Athletic Director’s Desk Reference. Champaign, IL: Human Kinetics. This publication includes over 300 downloadable forms, risk assessment checklists, and policies and planning tools which are designed to be customizable for your institution.