Chiles High School - Student Affairs Office
2018 – 2019 term Application for OFF- CAMPUS LUNCH Privilege
Off campus lunch privilege is reserved for classified Senior & Juniors in accordance with Leon County School policy 3.03(8).
To Qualify for an Off Campus Lunch Pass:
1. Juniors and Seniors who have earned at least a 2.0 un-weighted GPA or higher during the
Preceding 9-Week Grading Period are eligible for off campus lunch privileges.
Students must maintain an un-weighted 2.0 GPA to retain off campus privileges as well.
2. Parent/guardian Signature MUST BE legally NOTARIZED -OR- * the Parent/guardian may sign form in
front of a Chiles staff member here at the school.
3. Student must not have any unresolved Attendance Failure or have any Obligations to obtain the pass.
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 leave
PRINT Student’s LEGAL FIRST & Last NAME
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.
Their 2018-2019 grade level (Circle one): Senior OR Junior
__________ _______________________ x___________________________________
Parent/Guardian- PRINTED Name x Notarized Parent/Guardian SIGNATURE *
Address:______________________________________________________ Parent Cell Phone:____________________________________
_______________________________________________________________________________________________________________________________________
*Notary Section
Sworn to and subscribed before me this _________ day of ____________________, 20_______.
Signature of Notary Public_________________________________________
Official Seal:
SCHOOL USE ONLY: 2018/2019 Form
Student #:__________________________________ Classified Grade: level : 12
t
h
/ 11
th
Previous Unwt GPA: Accepted / No Obligations: No Yes
STUDENT MUST SIGN THE NEXT PAGE
Violations and Consequences may include but are not limited to:
VIOLATIONS
1. Leaving campus during lunch without an off-campus pass.
2. Reckless driving, speeding, not wearing seat belts, or other driving violations
3. Transporting unauthorized students off- campus during lunch
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 (* The Attendance Office holds the right to revoke my pass)
CONSEQUENCES
Student Affairs Office:
o After School Work Detail
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 have read this document and agree with all of its terms. I understand that Off Campus Lunch
is a privilege, not a right and that I am to conduct myself in a positive manner.
________________________________ ______________________________
Print Student Name Student Signature
2018-2019 Term Allow one business day to process during school session
We do not process/issue lunch passes the very first week of school, please plan ahead
