ClaytonValleyCharterHigh School

1101 Alberta Way, Concord, CA 94521Phone: 925-682-7474Fax: 925-825-7859

SENIOR BALL – Guest Pass Application Request

CVCHSStudent:

Name______Home Phone______Date______

(Please Print)

Guest requirements to attend the dance:

  • One Guest per CVCHS student.
  • Guest must be approved prior to purchasing their ticket.
  • CVCHS student is responsible for informing guests of all CVCHS behavior, dance, and dress expectations.
  • Guestmust be in good standing with their school (discipline, attendance).
  • Guests must be between the ages of 14 – 20. (No middle school guests are allowed.)
  • All Requests are subject to approval by Administration from both schools (if applicable).
  • Incomplete and /or Late Requests will be automatically denied.
  • Guest must show driver’s license and/or student photo I.D.card for admission to the dance.
  • Any person attending a CVCHS activity must agree to submit to a Breathalyzer or other recognized test to establish or disprove the use of alcohol or controlled substances.
  • Tickets are Non-Refundable, NO tickets will be sold at the door!
  • CVCHS Student and Guest will not be allowed to leave the dance until30 minutes prior to the conclusion of dance.

Guest Information:

Name ______Student I.D. or CDL # ______High School/College

Guest Address: City: Phone #

Age: ______Date of Birth: ______

Your signatures below implies consent and agreement to abide by

ALL school rules and policies while in attendance at this activity.

GUEST’S Signature ______Date

GUEST’S Parent’s Signature Date______

(Ifguest is under 18 yrs of Age)

GUEST’S EmergencyContact:______PhoneNo.

Adult Emergency Contactavailable night of event/dance

This section for non - CVCHS HIGH SCHOOL AGE guests only!
If guest is attending high school, an administrator of their school must sign below:I acknowledge that our student has an acceptable behavior record and is eligible to attend dance/event at our school and therefore eligible for the ClaytonValleyCharterHigh School event. GuestPass will not be considered without signature and school official’s business card.
GuestSchool Official Signature:______
Date: / Please attach Guest’s Administrator’s
business card here
(or copy of business card)

CVCHS Student and Parent: This is an understanding that you are responsible and liable for your guest’s actions and consequences. You are subject toany restitution or disciplinary actions that your guest’s behavior may cause.

CVCHSStudent’s SignatureDate

CVCHS Parent: I understand that my son/daughter will be taking a guest to this dance/event and that the date’s poor behavior can result in consequences for my son/daughter

CVHS Parent SignatureDate

Submit your completed application to Student Services for Administrative review and signature. Please allow 24 hours for approval. Pick up your signed form in Student Services prior to purchasing your guest’s ticket. If your Guest is not approved, you will be notified by a CVCHS Administrator

Approved By CVCHS Administrator X______