Harrison High School Off Campus Permission

Junior Leave Form 2021/2022
THIS FORM MUST BE SUBMITTED FOR ANY JUNIOR SEEKING LEAVE PRIVILEGE DURING HIS/HER ASSIGNED LUNCH PERIOD. Completed forms are due prior to students receiving permission to leave campus.
Last Name of Student *
First Name of Student *
Part Time BOCES student? *
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Student's Email *
example@example.com
Home Phone *

Area Code Phone Number
Student Cell Phone *

Area Code Phone Number
Parent Work Phone

Area Code Phone Number
Parent Cell Phone *

Area Code Phone Number
Parent E-mail (s) *
separate each additional e-mail with a comma

CAMPUS POLICY: Juniors, with signed parental permission and authorization from the administration, may leave campus during their assigned lunch period only. Juniors may not drive or park on campus. The administration reserves the right to deny, grant, or withdraw off-campus leave privileges to any junior or senior at any time during the school year.

**Note: Students are prohibited by Board Of Education policy from driving other students to and from BOCES**
I give my permission for my son/daughter, ______________________________, a JUNIOR in good standing, to leave campus during his/her lunch period only in an automobile driven by his/her parent.

**By entering your name in the space below, you are giving your electronic signature
Parent Name (digital signature) *
Entering your name is your digital signature
I also give my permission for my son/daughter above, to leave campus (during his/her lunch period only) in an automobile driven by a SENIOR student who has been granted driving/parking and leave privileges by the school administration.

**By entering your name in the space below, you are giving your electronic signature
Parent Name (digital signature) *
Entering your name is your digital signature
I accept the privilege of being allowed to leave campus during my lunch period for the 2021-22 school year with the understanding that if I violate a school rule, I may, in accordance with the Harrison High School Code of Conduct, lose this privilege for a minimum of 10 days.

Students must abide by the current COVID guidance from the Department of Health and follow any COVID protocols in place by the school.

See Student Handbook online at: http://www.harrisoncsd.org/docs/hhs/studenthandbook.pdf

Additional violations of the Code of Conduct may result in my leave privilege being revoked for the remainder of the school year and may result in my driving/parking privilege being suspended for the first semester of my senior year.

I have read and agree with the above statement.
Parent Name (digital signature) *
Entering your name is your digital signature
Student Name (digital signature) *
Entering your name is your digital signature

Thank you for completing this Form

For questions related to this form, please call Larry Mastrota at 914-630-3119 or via e-mail at MastrotaL@harrisoncsd.org
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Junior Leave Form 2021/2022

Thank you for completing this Form