4th Grade Science Safety Acknowledgement Form

Note to Parents/Guardians: Please take some time to review the following safety acknowledgement
with your child and sign in the spaces provided. Please also indicate any allergies that your child has. If
you have any questions, please don’t hesitate to contact your student’s teacher or school administrators.

Safety Rules:
1. ALWAYS LISTEN FOR DIRECTIONS AND WAIT TO TOUCH ANY LAB MATERIALS UNTIL
GIVEN PERMISSION.
2. NEVER EAT, DRINK, OR TASTE ANYTHING WHILE IN SCIENCE CLASS.
3. ALWAYS TELL YOUR TEACHER IF YOU SEE SOMETHING UNSAFE, INCLUDING BEHAVIOR.
4. NEVER PARTICIPATE IN HORSEPLAY.
5. ALWAYS REMIND OR TELL YOUR TEACHER ABOUT YOUR ALLERGIES.
6. NEVER EXIT SCIENCE CLASS WITHOUT WASHING YOUR HANDS WITH SOAP AND
WATER.
7. ALWAYS WEAR YOUR PROTECTIVE EQUIPMENT (GOGGLES & LABCOAT). WHEN MY
TEACHER IS WEARING THEIRS, I WILL BE WEARING MINE.
8. NEVER TOUCH OR PICK UP BROKE GLASS. REPORT IT IMMEDIATELY TO TEACHER.

What are you safety concerns and what is your student allergic to? (please list them all)_
_______________________________________________________________________.

What’re we learning about this year?

• Energy: speed, transfer, collision, and conversions
• Waves: Amplitude, wavelength, light reflection, transfer of information
• Molecules to Organisms: internal and external structures used for survival, growth, behavior, and
reproduction. As well as, information gathering, processing, and responding.
• Earth’s Place in the Universe: Rocks can show us how the Earth’s landscape has changed overtime
• Earth’s Systems: Weathering, erosion, and map data.
• Earth and Human Activity: Natural resources and natural processes, and how they impact humans.

Agreement: I have read and understand this form. I was present when these safety guidelines were
discussed in class or I discussed them with my teacher. I am aware that science class may have hazards
that could make it unsafe. I acknowledge that it is important that I follow the above safety procedures
to help make it a safer learning environment. Revised from: National Science Teachers Association—1840 Wilson
Boulevard—Arlington, VA 22201 October 2017 (www.nsta.org/safety)

Student Signature Date

I have read and reviewed the science class safety rules with my child.

Parent/Guardian Signature Date

Teacher Signature Date