M V H S

ONTA

ISTA

IGH

CHOOL

21840 McClellan Road Cupertino, CA 95014-4055 (408) 366-7600

November 2nd, 2012 Blood Drive Release Form (Community Commission)

*Must be turned in to Ms. Mandac in ASB by the end of lunch on Wednesday, October 31th, 2012 You will not be excused for forms that are incomplete or late. Student Name ___________________________________ Student ID _______________ If your appointment takes up part of the next period, you will be given a pass that excuses you from the beginning of your next class. You must get the following signed by the teacher whos class you are missing. You are responsible for making up all work missed. Donor Period Teacher Name: ______________________ Teacher Approval __________ Parental Approval
I hereby grant permission for the above named student to leave miss class to donate blood on Friday, November 2nd at Monta Vista High School. I hereby waive any and all claims which either of us may have, jointly or separately, against the Fremont Union High School District and/or the State of California and/or their officers, agents, or employees, for injury, accident, illness, or death occurring during, or by reason, of the above described retreat. I further agree to indemnify and hold harmless the Fremont Union High School District and/or the State of California and/or their officers, agents, or employees, from any and all claims, penalties, or losses resulting from, or as a consequence, of said retreat.

Parent Signature: _______________________________________________________ Date:________________________

MONTA VISTA HIGH SCHOOL

21840 McClellan Road Cupertino,CA 950144055 (408)3667600