Science Research Program Guide - Secondary Programs Home ...

VII. I/We give/withhold my/our permission for the student identified above to participate in
the following specific activities. (Please circle yes or no for each item).
A. Travel to/from libraries, universities, or laboratory facilities.
1. With an adult driver who has an insurance statement on file. YES
NO
2. With a student driver who has an insurance statement on file. YES NO
3. On his/her own recognizance i.e., walk, bicycle, or drive. YES NO
B. Travel to/from all science related field trips i.e., (a) local or regional science fairs, (b)
regional student talent search, (c) state science fair, (d) state student talent search, (e)
state science and humanities symposium, (f) International Science and Engineering
Fair, (g) Westinghouse Student Talent Search.
1. With an adult driver who has an insurance statement on file. YES
NO
2. With a student driver who has an insurance statement on file. YES NO
3. On his/her own recognizance i.e., walk, bicycle, or drive. YES NO
C. I/We approve release from school during the school day for research activities, i.e.,
(a) any activities listed in (A) or (B) above, (b) to store for materials, (c) to another
school, (d) for field collecting, (e) home for materials.
1. With an adult driver who has an insurance statement on file. YES
NO
2. With a student driver who has an insurance statement on file. YES NO
3. On his/her own recognizance i.e., walk, bicycle, or drive. YES NO
VIII. ___________________________________ ___________________________________
(Print or type parent’s name) (Print or type student’s name)
___________________________________ ____________________________________
(Parent’s Signature) (Student’s Signature)
_________________________________________________ Place notary seal here
(Street address)
______________________ ____________________
(City) (Zip code)
______________________
(Telephone No.)
Notary Signature ____________________________________ Date ________________
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