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
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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