CAMPBELL-SAVONA JR/SR HIGH SCHOOL
PROM PROMISE
PARENT/STUDENT CONSENT FORM
DATE:
May 9, 2015
TIME:
11:30 p.m. – 6:00 a.m.
LOCATION: Campbell-Savona Jr/Sr High School
PROM PROMISE is a “commitment” by each participant to be drug and alcohol free, especially on Prom
Night. Prom Promise is also an exciting activity sponsored by the PTSO and held after the Prom. Prom
Promise is offered to all Campbell-Savona juniors and seniors and their approved dates. Juniors and seniors
are not required to attend the prom in order to participate in the Prom Promise Activity.
Students participating in Prom Promise will be expected to follow the same rules as if they were in school.
Please note specifically the following School rules:
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

The possession or use of tobacco products, alcohol, or illegal drugs is not permitted.
Students will be expected to follow the district code of conduct. Appropriate behavior is expected.
Students are expected to arrive at the location no later than 12:30 a.m. and should plan to change
their clothes at Prom Promise. If a student fails to register on time, parents will be contacted.
Students will be required to stay at Prom Promise through the night and will be dismissed at 6:00
a.m. Parent/guardian must sign out their student if they would like to leave prior to 6:00 a.m.
Parents need to fill out the emergency consent form. Please indicate another name and phone number that
will be responsible for your child if you are out of town. Parents will be contacted if necessary.
THE PROM PROMISE
I will make a difference.
I refuse to be a statistic.
I refuse to live with the guilt of making a wrong decision,
And refuse to wait until it is too late.
I will not only live my life in the present, but will also live a life with
Hopes for the further.
I will not let alcohol and drugs determine the outcome of my life, or
The life of an innocent victim. Regardless of where
I am from, who I am, and what I believe, my life is
Worth more than any destructive decision.
I am willing to give up those selfish desires that destroy humanity, in
An attempt to create a safe, sober
And drug-free America.
I will not wait until prom to make this promise.
The form on the reverse side must be completed in order for your child to participate in the Prom Promise
Activity.
PARENT  TEACHER  STUDENT  ORGANIZATION
CAMPBELL-SAVONA JR/SR HIGH SCHOOL
PROM PROMISE
PARENT/STUDENT CONSENT FORM
DATE: May 9, 2014
Please Print Neatly.
TIME: 11:30 p.m. – 6:00 a.m.
LOCATION:
Campbell-Savona Jr/Sr High School
STUDENT INFORMATION
STUDENT NAME:________________________________________________________________________________________
HOME SCHOOL:_____________________________GRADE:____________AGE:________

Male

Female
HOME ADDRESS:________________________________________________________________________________________
Street
City
State/Zip
HOME PHONE:______________________________________STUDENT CELL PHONE:_______________________________
T-SHIRT SIZE: (If offered, please circle one)
SMALL MEDIUM LARGE XLARGE
PARENT/GUARDIAN INFORMATION
XXLARGE
PARENT/GUARDIAN NAME:_______________________________________________________________________________
PARENT/GUARDIAN CELL PHONE:____________________________________
MEDICAL INFORMATION
MEDICAL/HOSPITAL INSURANCE:________________________________________________________________________
SPECIAL MEDICAL INFORMATION WE SHOULD KNOW:____________________________________________________
________________________________________________________________________________________________________
PRESCRIPTION/NON-PRESCRIPTION MEDICINES STUDENT WILL BE TAKING:_______________________________
________________________________________________________________________________________________________
EMERGENCY CONTACT(S)
NAME OF PERSON TO BE CONTACTED:____________________________________________________________________
RELATIONSHIP:_______________________________________PHONE:___________________________________________
NAME OF PERSON TO BE CONTACTED:____________________________________________________________________
RELATIONSHIP:_______________________________________PHONE:___________________________________________
AGREEMENT
I have read, understand and agree with the rules and regulations governing the Prom Promise Activity. I authorize Prom Promise
Activity Chaperones to seek any required medical attention for my son/daughter during this event. As the parent, I also give
permission for my son/daughter to attend this event and release the School District or any other facility that hosts the Prom Promise
from any accountability should my son/daughter be injured during Prom Promise.
Parent/Guardian Signature:___________________________________________________________Date:___________________
Student Signature:__________________________________________________________________Date:___________________
PARENT  TEACHER  STUDENT  ORGANIZATION