Walt Whitman High School
Senior Class of 2014/2015 Lunch Pass Request
----Request for permission to leave campus during lunch --–
Note: Submission of this form does not guarantee that permission has been
Granted. An official pass signed by the principal is necessary.
The senior identified below has requested permission to leave campus during his/her designated
lunch period to eat lunch at one of the eating establishments in the community. Permission will only be
considered if the parents concur with the request. If the parents feel the student can handle the
responsibility and will comply with the stipulated regulations, then they should sign this form
indicating they approve the request, and are granting permission for the student to leave school
grounds and assume responsibility for the student’s behavior away from school.
Students who are granted permission to leave campus during lunch must comply with school
regulations and the following rules: failure to do so will result in the immediate revocation of the
privilege to leave campus.
Student will demonstrate safe driving and obey the posted speed limits and parking
regulations.
2.
Students are expected to be on time to all classes before and after lunch.
3.
Students are not permitted to take students who do not have permission to leave
campus to lunch. This includes underclassmen and seniors who do not have
permission to leave campus.
4.
Students will keep the streets free from trash and litter.
5.
Inappropriate behavior in restaurants will result in loss of privileges.
6.
Students granted permission and issued a lunch pass are required to carry it at all
times and present it upon request.
7.
Smoking in vehicles on school grounds is prohibited.
8.
Complaints raised by the community about specific students may result in a loss of
lunch privileges.
9.
Students who allow underclassmen to leave campus in their vehicles during lunch
will automatically forfeit their privilege to leave campus for lunch for the remainder
of the year.
In signing this form parents and seniors acknowledge:
 Leaving campus for lunch is a privilege.
 The senior has read this form and agrees to its rules and regulations.
 The senior will assume the responsibilities of this privilege in a mature manner.
1.
PLEASE RETURN SIGNED FORM TO SENIOR CLASS MAILBOX IN THE MAIN OFFICE
Student Name: _________________________________Home Phone: _________________________
Student Signature: ___________________________________________________________________
Parent(s) Signature: ____________________________Daytime Phone: _________________________
Parent(s) Signature: ____________________________Daytime Phone: _________________________
(Note: Parents may be contacted to verify signatures)