Fax#
317-216-5473
Due Before
April 19, 2017
Pike High School
Prom Guest Request Form
Instructions:
A student requesting to bring a guest to the Prom, who is NOT a Pike High School student or is NOT a Senior or Junior at Pike High
School, must have this form completed. This form must be returned to Mr. Csikos 24 hours before you plan to purchase your prom
tickets. THE MINIMUM GRADE LEVEL FOR ALL GUESTS IS 10 th GRADE AND ALL GUESTS MUST BE 20 YEARS OF AGE OR
YOUNGER ON April 23, 2017.
Pike High School Student Information:
As a Pike High School student, I understand that all Pike High School rules apply at school social functions. I will take full responsibility
to inform and ensure that my guest complies with these rules. I understand that my guest must always have photo identification in
his/her possession.
__________________________
Student Signature
__________________________
Student Printed Name
_________
Grade
___________________
Date
As the parents of the above named Pike High School student, I find his/her date to be a responsible person, and I approve him/her as an
acceptable guest for this Pike High School event.
____________________________________________
Parent Signature
__________________
Date
____________________________________________
Phone Number
__________________________________________________
Email Address
Guest Information – For All Non-Pike Students (PLEASE PRINT):
1. If your guest is no longer attending high school:
(You must submit a copy of driver’s license or State ID)
Name of Non-High School Guest: ___________________________________ Date of Birth: ______________
My Out of School Guest Graduated From: _________________________________ High School.
Guest Phone Number: _____________________________________
2. If your guest is a current high school student at other high school or a Sophomore at Pike High School:
(You must submit a copy of driver’s license or School ID.)
Name: ___________________________________
High School: _____________________________________________
Grade: _________________
Guest Phone Number: _____________________________________
As the Principal/Administrator of________________________________ High School, I verify that the student listed above is in good
standing at our school.
__________________________________________
Administrator Signature
__________________________________
Official Title
______________________
Phone Number