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Hathaway Brown School : Dance Guest Pass Instructions: Hathaway Brown students must complete ths form and turn it into the Dean of Students’ Office a least three days prior to the dance. Name of Dance: BCA DANCE Theme: Warehouse District Dress Casual Date of Dance: Friday, January 8. 2010 HB Student Name HB Student Grade Guest Name Date of Birth Guest Street Address, Guest City/State/Zip ‘Guest Parent Name(s) ‘Guest Home Phone, ‘Guest Emergency Contact Guest Emergency Phone By signing this form, the guest agrees to abide by Hathaway Brown’s Drug and Alcohol Policy, which forbids use or possession of alcohol or drugs before or during school functions. Violation of this policy will result in removal from the dance, notification of parents, along with notification of appropriate administrators at the guest’s school. Guest Signature ee eat eee ee eee Guest High School Principal: By affixing my signature | hereby attest thatthe student mentioned above is enrolled in my school and has Fmaintained acceptable standards of behavior, attendance and academic performance. ‘High School Name Principal Head of Upper School/Dean of Students Signature Date Deans Office Only Date Rec’d: Dean of Students Hathaway Brown School Phone: (216) 320-8769 / Fax: (216) 320-8794 or Fax. (216) 371-1501