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Mother/Guardian’s name Father/Guardian’s name Other (include name and relationship) Other (include name and relationship Home Phone: Cell Phone: Home Phone: Cell Phone: Home Phone: Cell Phone: Home Phone: Cell Phone: Phone: Name of carrier: Policy number: Subscriber’s name: Effective date:
Student’s doctor Medical insurance
Permission is hereby given for the above student to participate in the Baldwin High School Project Graduation 2011 (all night celebration) from Friday, May 20, 2011 9:00 pm to Saturday, May 21, 2011, 6:00 am. I authorize the Baldwin High School Project Graduation designated chaperone(s) to accompany my child to a medical facility and allow the on duty physician/nurse to administer care and treatment for any emergency illness or injury during this event. Acetaminophen (Tylenol) and Motion Sickness Relief tablets (Dramamine) will be available upon request. My child is allowed to take the over-the-counter medications as needed. Please check one: ____ Yes ____No Special health conditions:
Allergies (food, medication, other):
List below the medications that your child will be bringing with to Project Grad (include brand name and dosage). Medications will be turned in during registration. Chaperones will hold medication for your child during the event.
Signature of Parent or Guardian
(PRINT – Student’s Last Name, First Name)
Baldwin High School Project Graduation 2011 Authorization Form
A. Waiver of Liability In consideration of being allowed to attend the Baldwin High School Project Graduation 2011, the undersigned confirms that: 1. I am a parent /guardian of the student named above. 2. I understand that Baldwin High School Project Graduation 2011 is not an “official” H.P. Baldwin High School event or State of Hawaii Department of Education event. 3. In the event of any unforeseeable accident or injury, I agree that the State of Hawaii Department of Education, H.P. Baldwin High School staff, Baldwin High School Project Graduation 2011 Committee, the County of Maui and the State of Hawaii will not be liable. 4. I hereby give my permission to the Baldwin High School Project Graduation 2011 Committee to videotape or otherwise record my child’s name, voice and/or likeness and use my child’s name, likeness, and/or bibliographical information for promotional purposes. B. Authorization for graduate pick-up I am aware that my child must be picked up at the Baldwin High School Gym at 6:00 am, Saturday, May 21, 2011. _____I will be picking up my child that morning. _____I have designated the following person to pick up my child. (Must be 21 years of age or older) Print name:________________________________________ Relationship to student:_______________________________ Phone number:______________________________________ C. Rules and Guidelines 1. Parent/Guardian: I have read all of the Project Graduation Rules and Guidelines and am confident that my son/daughter will abide by them. I agree that when notified that my child is not obeying any of the rules and guidelines set forth; I will pick up my child immediately. ________________________________ (Print name of Father/Legal Guardian) ________________________________ (Print name of Mother/Legal Guardian) _________________________________________ (Signature of Father/Legal Guardian) Date _________________________________________ (Signature of Mother/Legal Guardian) Date
2. Student: I understand that if I violate any of the Project Graduation Rules and Guidelines or if I am apprehended with alcohol or illegal drugs in my possession, my parent(s) or legal guardian(s) will be notified and must pick me up immediately. ______________________________ (Print name of student) _________________________________________ (Signature of student) Date Parent Copy – Keep for Reference
Baldwin High School Project Graduation 2011 Rules and Guidelines
1. Only graduating Baldwin High School seniors who have registered for Project Graduation 2011 will be allowed to participate. 2. Check-in: All registered graduates must check in with a parent/guardian at the Project Graduation table, located outside the Baldwin High School Gym by 8:45 pm on Friday, May 20, 2011. The graduate must be declared drug-free (including cigarette) by the accompanying parent or guardian. Parents/guardians may be required to present a picture I.D. 3. Pick up/Sign out: Graduates must be picked up on Saturday, May 21, 2011, by 6:00 am at the Baldwin High School Gym. Graduates must be signed out and will only be released to an authorized parent, guardian or adult (21 years of age or older) with proper ID. Graduates will NOT be allowed to operate any moving vehicle due to fatigue. 4. Attire: Graduates should plan to bring a change of clothes so that they can change from their graduation ceremony attire to comfortable clothing. A Project Graduation t-shirt will be provided to each participant. Also, bring a sweater or jacket. Footwear (shoes or slippers) are required. No more than two (2) leis (no edible or drinkable leis) may be worn to the Project Graduation event. 5. Prohibited Items: Please do not bring any electronic devices (cell phones, cameras, pagers, CD players, MP3 players, iPods, electronic games, etc.) Do not bring any purses, wallets, handbags, car keys, or backpacks. Students will not need money for any Project Graduation activities. 6. Items to be provided: Toiletry items (toothbrush, toothpaste, feminine personal products, etc.), meals/snacks, and a Project Graduation t-shirt will be provided. 7. No shows: NO refunds will be made for registered participants who do not check in. Parents of “No-Show” participants will be notified by telephone after seniors have departed for the event. The Project Graduation committee will not be responsible for these “no show” participants. 8. Participating seniors must remain with the group until the Project Graduation event concludes on Saturday, May 21, 2011 at 6:00 am. If a senior must leave due to illness or other circumstances (being unruly, in possession/use of alcoholic beverages or drugs including cigarettes), the individual will only be released to an authorized parent, guardian, or adult (21 years of age or older) with proper ID. No return passes will be issued. 9. Adult chaperones and security will be provided at the Project Graduation location and during transportation of participants. In the event of an emergency and parents need to contact their child, please call designated chaperones (chaperone cell phone numbers will be provided at Mandatory Parent Meeting) 10. Parents/guardians will be responsible for any property damage done by their child during the Project Graduation event.