Santa Rosa Community School

NAVARRE HIGH SCHOOL CLASSES

DATE:

CLASS NAME:

LOCATION:

Childs Name:
DOB:

Childs SS#:
Age:

Sex: M or F

Address:
Home Phone:

City/State/Zip:
Doctors Name:

Phone #:

CURRENT GRADE LEVEL (Circle One): 3 4 5 6 7 8 9 10 11 12

Mothers Name:

Fathers Name:

Address:

Address:

Place of Work:

Place of Work:

Work Phone:

Work Phone:

Persons to be contacted if parents cannot be reached - Also authorized to remove child from
facility: (Must list 2)
Name

Phone

Relationship

1.
2.
3.
Does your child need a medicine release form? Yes
No
Special instructions/Health Problems: (anything to benefit the care of your child)

Receipt #:
Officer:

Date:
Book Number:

Fee Paid:
Site:

Navarre High

Start Date:

I, the undersigned parent/guardian of

,a
minor, do authorize Patrick G. McLellan, Director, Santa Rosa Community School, or his
representative, the custody of said minor for the portion of time the said minor attends the Santa
Rosa Community School programs. I also authorize Navarre High School to transport the said minor
to the site of activities and in the event that it may become necessary, including but not limited to,
engaging a physician or hospital to provide medical services. I further authorize and agree to hold
harmless the Santa Rosa Community School, Navarre High School and Santa Rosa County School
Board from any and all liabilities arising from the Community School programs, save and except
negligence. I understand that if the said minor becomes a disciplinary problem that said
minors participation in the program may be suspended or terminated. In either case, NO
REFUND will be issued. I also authorize Patrick G. McLellan or his representative to use my childs
name and/or photograph at his discretion for both training and publicity regarding the Santa Rosa
Community Schools programs. I further agree that I will abide by these procedures as long as my
child participates in the Community School Program.

Parent or Legal Guardian

Personally known or
Identification
Sworn to and subscribed to me this
of
in the year of our Lord
My commission expires

day

It is the policy of Santa Rosa County to

offer the opportunity to students to
participate in appropriate programs,
services, and activities without regard
to race, color, religion, national origin,
sex, marital status, or disability.

Notary Public, State of Florida at Large

THIS SECTION MUST BE COMPLETED IN ORDER TO MAKE PAYMENT BY CHECK

Name:

Sex: Male

Female:

Address:

Race:

DOB:

City/State/Zip:

Hair Color:

Eye Color:

SSN:

Height:

Weight:

D L Number:
Employment Address:
Signature:

State

Employer:
Work Phone: