EMPLOYMENT CONSENT FORM — CALVARY ACADEMY

EMPLOYMENT PRIVILEGE FORM

I hereby certify that my student is permitted to depart from the Calvary Academy Campus before the hour of dismissal (3:30 p.m.). I am aware that my student must meet all academic assignments, maintain exemplary conduct, retain a grade point average of 2.7, refrain from receiving more than three tardies in one consecutive semester, and procure daily permission from the administrator. I am aware that if my student fails to comply with the regulations presented, he will be suspended from his privilege by the administration of Calvary Academy for a total of three weeks.

STUDENT NAME

First Name

Last Name

PARENT/GUARDIAN NAME

First Name

Last Name

STUDENT GRADE

PLACE OF EMPLOYMENT

HOURS OF EMPLOYMENT

DAYS OF EMPLOYMENT

MONDAY-FRIDAY

TUESDAY & THURSDAY

MONDAY, WEDNESDAY, & FRIDAY

OTHER (PLEASE SPECIFY)

EMPLOYER PHONE

(###)

###

####

PARENT/GUARDIAN EMAIL

PARENT/GUARDIAN PHONE

(###)

###

####

PARENT/GUARDIAN SIGNATURE

Full Name Below

STUDENT SIGNATURE

Full Name Below

EMPLOYMENT PRIVILEGE FORM

THE LOWER CAMPUS

THE UPPER CAMPUS