Chiles High School - Student Affairs Office
2019 – 2020 term OFF- CAMPUS LUNCH Pass Application
Off campus lunch privilege is reserved for classified Senior & Juniors in accordance with Leon County School policy 3.03(8).
To Obtain an Off Campus Lunch Pass:
1. Juniors & Seniors who have earned at least a 2.0 un-weighted GPA or higher during the preceding nine-week
grading period are eligible for off campus lunch privileges.
2. Parent/Guardian Signature MUST BE LEGALLY NOTARIZED* -OR- the parent/guardian may sign this form in
front of a Chiles Staff member here at the school.
3. Students must be clear of all attendance failures and Obligations (Fines/fees, books etc..)
4. Student must be present for pass to be processed – Photo taken !!
Parent/guardian complete this section:
This is to certify that __________________________________________ has my permission to
PRINT Student’s LEGAL FIRST & Last NAME
leave Chiles campus during the lunch period and that I accept full and complete responsibility for my
student during the time he/she is off campus.
2019-2020 grade level (Circle one): Senior OR Junior
__________ _______________________ x_____________________________________
Parent/Guardian- PRINTED Name x Notarized Parent/Guardian SIGNATURE *
Address:______________________________________________________ Parent Cell Phone:____________________________________
A n otary is a person licensed by the government to perform acts in legal affairs, in particular witnessing signatures on documents.
* Notary Section
Sworn to and subscribed before me this __________ day of __________________________, 20_______.
Signature of Notary Public_________________________________________
Official Seal:
SCHOOL USE ONLY: 2019/2020 Form
Student #:______________________________ Classified Grade: level : 12
th
/ 11
th
Previous Unwt GPA: Accepted / No Obligations: No Yes
STUDENT MUST SIGN THE NEXT PAGE
Off Campus Pass Policy Infractions and Consequences
VIOLATIONS
1. Students with off-campus lunch privileges will not take students off campus who are not authorized to leave. This includes other
juniors and seniors who have not been granted permission OR who do not have valid off-campus pass in hand.
2. GPA – must maintain at least 2.0 un-weighted each grading period
3. Reckless driving, speeding, not wearing seat belts, or other driving violations
4. Excessive tardiness (over 3) to fifth period class after lunch (* The Attendance Office holds the right to revoke my pass)
5. Failing to return to class after lunch without signing out in the Attendance office prior to departing for lunch.
6. Two referrals within 30 days will result in suspension of pass
7. Drugs, alcohol, tobacco or weapons found in any vehicle will result in revocation.
8. Attendance failure(s) (* The Attendance Office holds the right to revoke my pass)
CONSEQUENCES
o Saturday School Detention
o Suspension of Off Campus/ Parking Privileges
o Revocation of Off Campus/Parking Privileges
o In School Suspension/Detention
o Out of School Suspension
I understand that Off Campus Lunch is a privilege, not a right and that I am to conduct myself in a
positive manner. I will obey all traffic laws and behave appropriately in area restaurants/businesses.
Reports from the community about inappropriate behavior may result in the revocation of an off-
campus lunch privilege.
I will be required to present my off-campus lunch pass upon leaving campus at lunch. Failure to produce
a valid student Lunch ID pass will result in a forfeiture of my right to leave campus on that particular day.
________________________________ ______________________________
Print Student Name Student Signature
2019-2020 Term (Allow one business day to process during school session)
We do not process/issue lunch passes the first three days of school.
