PARENT/GUARDIAN WORK-BASED LEARNING SAMPLE
PERMISSION FORM
My child,
,
(Name of Student)
participate in a school-to-work activity at
has my permission to
(Birth Date)
beginning
(Date)
(Work Site Location)
and ending
(Date)
I will be responsible for arranging transportation for my child to and from the work site. 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 the student is at the site and will not be responsible for my child.
TO BE COMPLETED BY THE SCHOOL REPRESENTATIVE:
Name of Employer:
Address of Employer:
Nature of Work:
Are employees/workers at this work site engaged in hazardous occupations?
Yes
No
Will the school-to-work opportunity for this student involve a hazardous occupation as defined under the
Federal guidelines:
Yes
No
Nature of work in the school-to-work opportunity:
Employer/Contact:
Phone:
TO BE COMPLETED BY THE PARENT(S) OR GUARDIAN:
Transportation Arrangements:
Home Address:
Home Phone
The school 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.
(Parent/Guardian Signature)
(Date)
(Parent/Guardian Signature)
(Date)
Note: Return to coordinator
Adopted from the South Carolina Department of Education
(Work Phone)
(Work Phone)