Permission/Release Form - St. Anne's Catholic School

Please fill in all blanks

Student’s Name: Last First Nickname

Father's Name Mother's Name

Phone: Cell Phone: Pager Number:

Address:

Picture Release:

I give permission to St. Anne's School to use my child's picture in publications, press releases, etc. during the school year.

Yes No

(Please Check One)

P.E. Permission:

My child has permission to walk (or in case of inclement weather, to be driven) to the Virginia Intermont College Pool or Field, or to the Virginia High School Track during the school year as part of physical education classes. The child will be supervised by a classroom teacher and will remain with the class during the trip.

Yes No

(Please Check One)

Vision Screening:

I give permission for my child to have his/her vision checked during the school year.

Yes No

(Please Check One)

School Handbook:

We agree to abide by the rules and regulations found in the St. Anne's School Handbook.

Yes No

(Please Check One)

Signature of Parent or Guardian Date:

Please print out and return this form to the school: St. Anne's Catholic School, 300 Euclid Avenue, Bristol, Virginia 24201