APPLICATION
Terry Parker Off-Campus Lunch
Pass
2015-2016 School Year
(Student’s Printed Name) has my
permission to check-out of school during lunch. I understand that s/he is required to
check-out and check-in with the student services representative on a daily basis.
I,
(Parent/Guardian’s Printed Name), understand
that my son/daughter and I are responsible for his/her actions while off campus and in
no way will the school or a School Board employee be held responsible for the actions of
my child. Abuse of the off-campus lunch privilege or failure to comply with off-campus
guidelines may result in revocation of the privilege and/or other disciplinary action.
Parent/ Guardian’s Signature
Date
Contact #’s for Verification of Application
Home:
Work:
Cell:
- - - - - - - - - - - - - - - - - - - - - - Verified by Student Services Office:
Yes
No
I Authorize My Student To:
 Drive his/herself only
 Drive other off-campus lunch students
with their parents’ permission
 Ride with other off-campus lunch
students with their parents’
permission
**Pease check all that apply**
*Off-Campus lunch privileges start September 2015. Applications not verified by a
parent/guardian will not be processed. Academic standing is reviewed each nine weeks.
Students must maintain an unweighted GPA of 3.0 with no D’s or F’s on the report card.
**Please read and sign the Off-Campus Lunch Rules on back of this page**
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Off-Campus Lunch Rules
All students who receive the off-campus lunch pass privilege must adhere to
the following:
1.
Only Junior and Senior students can purchase an off campus lunch pass. Lunch passes
are $10 for students with a 3.0 GPA or higher and $15 for students with a GPA
between 2.5 and 3.0 Students with a GPA lower than a 2.5 are NOT eligible to receive
a lunch pass. Students may receive the privilege at a reevaluation time in January
after midterm grades are finalized. That dates is TBA.
2.
Due to weather or circumstances deemed necessary by administration, Off-Campus
lunch may be cancelled for any day. ALWAYS have lunch money available to purchase
lunch in the cafeteria.
3.
Students approved for off-campus lunch may not transport other students in their
vehicle unless the parent/guardian of both parties has given authorization and been
verified through the Terry Parker Off-Campus Lunch Pass form.
4.
The driver is responsible for all students in his/her car. If a student has not qualified to
be off campus, that student and the driver will receive consequences.
5.
A senior with an approved off-campus lunch privilege MUST return to school after lunch.
(All check-outs must go through Student Services before, during, and after lunch.)
Your off-campus lunch privileges can be suspended or revoked if you:
a. do not maintain the required GPA each nine weeks.
b. leave school without checking out through the Student Services representative.
c. transport or ride with another student who does not have appropriate approval.
d. have excessive tardies when returning from off-campus lunch.
e. have disciplinary infractions while on off-campus lunch.
f. do not return from off-campus lunch.
I have read, understand, and agree to abide by the Off-Campus Lunch Rules.
Student Signature:
Date:
Parent/Guardian Signature:
Date:
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