Chaperone Application Youth Ambassador Trip to Japan Chaperones must be a guardian of a participating student. Chaperone Name(Required) First Last Chaperone Date of Birth(Required) MM slash DD slash YYYY Chaperone Phone(Required)Chaperone Email(Required) Participating Student Name(Required) First Last Relationship to Student(Required) Emergency Contact Name(Required) First Last Emergency Contact Phone(Required)Allergies or other health concerns:(Required) Room with your participating student?(Required)Rooming with your student is not guaranteed, but it is a possibility. Yes No Homestay with your participating student?(Required)This will most likely happen. Yes No Please upload a copy of the chaperone's passport.Max. file size: 512 MB.Payment Instructions To avoid transaction fees (about 3%), please mail a check to "SSCA" at 2400 S. Scenic Ave., Springfield, MO 65807. Please note your name and "chaperone app" in the memo line. $200 deposit due with registration $2,640 due on Dec. 30, 2023 $990 due on March 30, 2024 Payment Method(Required) Mail a check Pay with card below Payment Amount Transaction Fee(about 3%) Price: $0.00 Total Credit Card Cardholder Name Card Details CAPTCHA
