Prom 2015 Travel Form
ID Verified
Date/Time
Indiana Academy for Science, Mathematics, and Humanities
Select one of the following options and fill out its corresponding box below:
Option 1 (Academy Transportation): My student is only taking Academy-provided transportation for the entire evening. My
to spend the night. The Academy will provide transportation to and from Cornerstone Center
for the Arts and After Prom.
Option 2 (Day Travel): My student will be riding in a non-Academy vehicle at some point during the evening. My student will
night. Student MUST take Academy-provided transportation to After Prom.
Option 3 (Overnight): My student will be going out overnight and will not be returning to the Academy for any reason during the
the night in Wagoner Hall.
Option 4 (NECP): My student is in the Non-resident Early College Program (NECP).
student will return to Wagoner Hall
return to Wagoner Hall to spend the
evening. My student will not spend
Option 3 : Overnight
Option 1 : Academy Transportation
Student Name:
Student Name:
My Student Will Attend:
Prom
After Prom
Student may attend After Prom without attending Prom
My Student Will Attend:
Prom
After Prom
Student may attend After Prom without attending Prom
Departure Date and Time:
Return Date and Time:
Parent/Guardian Emergency Phone:
Parent/Guardian Signature and Date:
Option 2 : Day Travel
Student Name:
My Student Will Attend:
Prom
After Prom
Student may attend After Prom without attending Prom
Departure Date and Time:
Student Must Return Car To Parent/ Guardian
Before Returning To The Academy
Person Signing Out Student:
Mode of Transportation:
Name of Driver:
Traveling Companions:
Return Date and Time:
Destination(s):
Person Signing Out Student:
Parent/Guardian Emergency Phone:
Mode of Transportation:
Name of Driver:
Traveling Companions:
Parent/Guardian Signature and Date:
To Be Completed When Student Is Signed Out On Day of Prom:
Car Make/Model/Color:
Designated Person’s Printed Name:
Today’s Date:
Designated Person’s Signature:
Person’s Contact Phone:
License Plate/Car Registered to:
Destination(s):
Time Student Will Return Car Keys To Front Desk (Student Must Turn In Keys By 12:30
AM):
Parent/Guardian must pick up car keys
no later than Sunday, May 10th at 10:30 PM
Parent/Guardian Emergency Phone:
Option 4 : NECP
Student Name:
My Student Will Attend:
Prom
After Prom
Student may attend After Prom without attending Prom
Mode of Transportation:
Name of Driver:
Parent/Guardian Signature and Date:
Designated Person’s Printed Name:
Student may take Academy Transportation to dinner, Prom, and/or After Prom. Please
indicate this as Mode of Transportation.
Traveling Companions:
Designated Person’s Signature:
Destination(s):
Student’s Printed Name:
Parent/Guardian Emergency Phone:
Student’s Signature:
Parent/Guardian Signature and Date:
To Be Completed When Student Is Signed Out On Day of Prom:
Today’s Date:
Person’s Contact Phone:
Office Use Only:
Verified by:
Verification Date/Time:
This form is due to The Indiana Academy Front Desk no later than Saturday, April
26, 2015. We cannot accept forms called in over the phone or faxed forms.
We must have an original signature.