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PARENT/GUARDIAN CONSENT AND LIABILITY WAIVER FORM

Student's Name Homeroom

Student is an 8th grade student at Dag Hammarskjold Middle School: Yes No______

Parent/Guardian Name: _____________________________________________


Home Phone Cell Emergency Phone _

I, , grant permission for my child, _,

to participate in Dag Hammarskjolds 8th grade Dance, to be held on Friday, May 26th from 7:00-10pm at
Club Lucent (25 North Plains Highway, Building B-across from the PNA Park in Wallingford). The Dag
Hammarskjold PTO and Dag Hammarskjold volunteer parents sponsor this activity.

I agree on behalf of myself, my child named herein, or heirs, successors and assigns, to hold harmless and
defend all chaperones, Dag Hammarskjold PTO or representatives associated with the event, from any claim
or damage to any person or property arising from our connection with my child attending the event, or in
connection with any illness or injury or the cost of medical treatment in connection therewith.

Participants must STAY FOR THE ENTIRE event unless accompanied by a parent or
1.
guardian.
2. No foul language, drugs, alcohol, tobacco or weapons are permitted.
3. Participants must respect the rights and property of others.
4. Participants and parents/ guardians are responsible for any and all damages caused by the
participant.
5. This is a school function. ALL SCHOOL RULES APPLY!
6. Failure to abide by the above stated may result in participant removal, by parent, from the
event.
7. Dress code must be followed:
BOYS ATTIRE: NO Jeans, T-Shirts or Athletic Shorts. MUST be collared shirt, khaki or dress pants
GIRLS ATTIRE: NO Strapless or Prom Dresses. Dress straps must be material, not plastic.
PLEASE BE AWARE OF LIGHTING AT THE CLUB. PROPER UNDER GARMENTS REQUIRED!
8. Participants must attend school the day of the dance-May 26th.
9. Anyone needing to enter the dance after 7:00pm must notify the PTO in advance by
contacting Kristen Hinckley @ 908-794-3876 or h i n k s h o p @ s b c g l o b a l . n e t

I give my permission for my child to be photographed for school use: Yes______ No_______

Parent/ Guardian Signature:___________________________________ Date:

Student Signature:______________________________________________ Date:

THIS SIGNED WAIVER FORM IS REQUIRED AT TIME OF TICKET PURCHASE!!!

NO EXCEPTIONS!!!