KEYSTONE HIGH SCHOOL
580 Opportunity Way, LaGrange, Ohio 44050
Phone (440) 355-5132 Fax (440) 355-6017
OUT-OF-SCHOOL GUEST APPLICATION
Keystone High School Function: After Prom 2016
Date/Location: Saturday, May 14, 2016 – Keystone High School 12-midnight – 3:00 am
Dress Code: Casual
Keystone students wishing to bring one non-Keystone student date to the above Keystone High School function must
receive approval from the Keystone High School Administration. This form must be completed and returned to the
After prom committee member prior to purchasing ticket.
The non-Keystone student must present a picture ID when he or she arrives at the event. All Keystone High
School rules will be in effect at this function and are applicable to both our student and the guest date. After entering
the building no one will be allowed to leave the building until the event is over. Please note that no Junior High
students are permitted to attend. No guests over 19 years of age will be permitted at this function without permission
from the Keystone High School Administration.
KHS STUDENT ESCORT INFORMATION / RESPONSIBILITY STATEMENT
Name: _______________________________________ Phone number: (
)_____-________
Parent Name:_______________________________________
I understand that I am subject to KHS disciplinary action based on the behavior and actions of myself and based on
the behavior and actions of my out-of-school guest.
Signed: _________________________________
(KHS Student Escort)
Date: _______________
Parent/Guardian signature acknowledging understanding of responsibility:
Signed:__________________________________ Date:________________
(KHS Student Parent/Guardian)
NON-KHS STUDENT INFORMATION / RESPONSIBILITY STATEMENT
Name:___________________________________________Age:__________
School Attending: _____________________ Phone number: (
Parent/Guardian Name: ________________Phone number: (
) _____________
) _______________
I understand that I am subject to all Keystone High School and Keystone Local Schools rules and responsibilities. I
furthermore understand that my KHS escort is equally subject to disciplinary actions based on my behavior and
actions.
Signed:_______________________________________
Date:________________
(Non-KHS Student Guest)
NON-KHS STUDENT PARENT STATEMENT OF UNDERSTANDING
My son/daughter has my permission to participate in the After prom. I understand that I am ultimately responsible for
his/her actions and behaviors. I permit KHS and Keystone local school staff and administration to take any action
necessary to maintain orderly conduct @ this function.
Signed : _____________________________________Date:______________________
(Non-KHS Student Parent/Guardian)
NON-KHS STUDENT PRINICIPAL AFFIRMATION STATEMENT AND SCHOOL SEAL
By affixing my signature and seal, I hereby attest that the student applying for out-of-school guest approval has
maintained acceptable standards of behavior, attendance and academic performance.
Signed: ___________________________________________Date:______________
(Non-KHS student school principal)
School Seal