Wm. S Hart Union School District 

ACTIVITY CLEARANCE CARD VALENCIA HIGH SCHOOL 2007-2008

Parent’s Consent     Insurance/Waiver   Co-Curricular Agreement

 NAME OF STUDENT________________________________GRADE_______PHONE__________

ADDRESS________________________________CITY_________ZIP______________

  Parent approves participation in the following:

ALL ACTIVITIES, TRIPS, COMPETITIONS, TOURS, AND REHEARSALS WITH THE VALENCIA HIGH CHOIRS
FOR THE 2007-2008 SCHOOL YEAR

CONCERT CHOIR, CHAMBER/VJ, MIXED CHORUS, WVE, MVE, BARBERSHOP

PARENTAL CONSENT AND CO-CURRICULAR AGREEMENT

I hereby consent for the above-named student________________________ to go with a representative of the school on any trips. In case of injury to this student, you are authorized to have him/her treated. I further understand that in case of injury, the school staff and student body are relieved of all liability from medical or hospital bills sustained in participation in school activities and agree to abide by the rules and regulations. (See Valencia High School student handbook – “Notice of Rights and Regulations, and Responsibilities.”)

PARENT SIGNATURE______________________________________DATE________

I have read the co-curricular policy regarding requirements for participation in school activities and agree to abide by the rules and regulations.

STUDENT SIGNATURE___________________________________DATE_______

PRIVATE INSURANCE COVERAGE (IF APPLICABLE) 

This is to certify that my child is covered by insurance and further, that said coverage will be in force for the entire current school year.

Medical Insurance Co._________________________________Policy No.____________

Parent Signature_______________________________________Date_______________

Work Phone:    Father (        )______________________________________________

                        Mother(        )______________________________________________

Other person to contact if parent cannot be reached

Name________________________________Relationship________________