Grade 9 Take Our Kids to Work™
Please complete and return this form to your school by Thursday, October 28 PART I – STUDENT
I would like to investigate an occupation on Take Our Kids to WorkTM day, Wednesday, November 3, 2010. I agree to arrive at the specified time and to abide by all the rules at the workplace. I understand that I am under the authority of the adult I am accompanying to work. ____________________________________ Student name (Printed) ____________________________________ Student Signature ____________________________________ School ____________________________________ Date

I authorize my child’s participation in Take Our Kids to WorkTM day, Wednesday, November 3, 2010. I understand that neither the Delta School District nor the sponsoring employer can be held responsible for any injuries that may result from participation in the program. I hereby release the Delta School District and the sponsoring employer and its employees and agents from all manner of action suits, losses, damages or injuries, however caused, arising out of my child’s participation in the program. My child will accompany me to work on November 3, 2010. My child will accompany a relative, neighbour or friend on November 3, 2010. Photo Release: I consent that photographs and interviews of my son/daughter for the occasion of this career exploration tour may be used for media publication within the school district and press releases to local newspapers.

____________________________________ Parent/Guardian Signature

___________________________________ Date

I will be taking the above–named student to work on November 3, 2010 and acknowledge that the student will be under my supervision for the hours indicated. ____________________________________ Name (Printed) Relationship: Parent/Guardian Relative ____________________________________ Occupation Neighbour Friend _________________ Phone _________________ Fax

____________________________________________________ Place of Employment

The student will be present at my workplace between the hours of _____ and _____. The student should bring a lunch. Yes No _________________________________ Employer Signature _________________________________ Date

I would like to learn about sponsoring student Work Experience or Secondary School Apprenticeship.

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