| ________________________ 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:______________________ |