________________________ Last Name, First Name (print) |
__________ Advisor |
PERMIT NUMBER_______ |
We have read and understand the above regulations and the consequences on the back, and will abide by them at all times.
Parent Date | Student Grade Date |
Daytime phone | |
Address | |
Driver's License Number | |
Make | Make |
Model | Model |
Year | Year |
Color | Color |
License Plate Number | License Plate Number |
Consequences Reviewed (date):________________ | Consequences Reviewed (date):________________ |
Student Signature:______________________ | Student Signature:______________________ |
Administrator:______________________ | Administrator:______________________ |