I, the undersigned parent/legal guardian, request that my child participate in the following voluntary work study program at the __________________ School District:

Name of student: ________________________________________________________

Name of program: ________________________________________________________

Semester/School year: ____________________________________________________

I understand that this work study program may require my child to attend activities off school campus. I understand that the School District will not provide transportation for my child’s participation in any off-campus activities, and that I am therefore responsible for arranging my child’s transportation to and from any such activities.

I affirm that any decision I make to allow my student to ride to or from the off-campus activities in a vehicle driven by anyone other than me (including one driven by my child) is a decision to be made solely by me, based upon my discretion as a parent or legal guardian and my own assessment of the safety of allowing such transportation to occur.

If the above identified student will use his or her personal vehicle for transportation, I affirm that:

1. The student driver has a valid driver’s license;

2. The vehicle is insured; and

3. The student will abide by school policy.

In requesting that my student be allowed to participate in this elective work-study program,

I agree and affirm that no person shall be considered to be acting as an agent or servant of the District, in any respect or for any purpose, whatsoever, while driving my student to or from this work study course. Should any claim be made against the School District based on the driving conduct of any person transporting my student to or from the off-campus activities involved in this elective course, I hereby agree to hold the District harmless as to such claim.

Furthermore, I hereby release and agree to hold harmless the School District from any claim or injury that may be suffered as a result of participation in the work study program.

________________________________ _________________________________

Parent/guardian (date) Student (date)

Based on the foregoing, the _______________ School District hereby grants permission for the above named student to participate in the work study program.


Superintendent/Designee (title) (date)