26 . Parent/Guardian Work-Based Learning Permission Form My child, _|Y\G/II ey ene. C ob ) has my permission to (Name of Student) Birthdate) 7, !/ 31/2006 participate in a work-based leaming activity at beginning (Worksite Location) and ending. STATOVE @ate) Date) 4/17 - Uy I will be responsible for arranging transportation for my child to and from the worksite. My permission is given for my child to receive emergency medical treatment in case of injury or illness. I understand that school personnel will not be present when my chitd is at the site and will not be responsible for my child. TO BE COMPLETED BY THE SCHOOL REPRESENTATIVE ‘Name of Worksite: Address of Worksite: ‘Nature of Work: NOTE: Students will not be allowed to ride in company vehicles, operate machinery, and handle hazardous materials during this shadowing work-based opportunity. ‘Nature of work to be performed in this work-based learning activity ‘Worksite Supervisor Contact: Phone: ‘TO BE COMPLETED BY THE PARENT OR GUARDIAN: ‘Transportation Arrangements: Home Address: Home Phone: The district shall not be liable for any injuries sustained by the student’s participation in this program. I have read the above information and fully understand and agree with the content. “ree 5 "ele UY2.S47,.23us- (Parent/Guardian Siemifc) (Date) (Work Phone) NOTE: Please include a copy of the “Workers? Compensation and Tort Insurance” ~ see pages 7-8. 8/15/17 — Revised 2