Gold Card holders are entitled to have one off-campus lunch (1 hour) on the designated day and month as listed below.  It is the responsibility of each student to have this form completed with all signatures prior to leaving campus.

 If you do not have a full hour for lunch and have a half-hour music class/study hall before or after your lunch period, you must have your teacher sign this form also. 

Extreme caution should be taken when leaving and returning to campus. Furthermore, it is your responsibility to return to campus on time for your next class.

_____________________________                              9            10           11           12

            Please print name                                                  Circle one

Date of release:                                                                      10/25

Lunch period:                    3            4            5               __________________________

                                         Circle one                             Teacher Signature

                                                                                     __________________________  

                                                                                      Student Signature and I.D. Number

_______________________________________

Parent Signature

_______________________________________

Student Signature