Permission Slip Form Grades 3-12

Parent Name *
Parent Name
Address *
Phone *
Student Name *
Student Name
Student's Date of Birth *
Student's Date of Birth
By typing my name below: I grant permission for my child to participate in and utilize The Shafter Learning Center (SLC) and I release of liability the City of Shafter on my child's behalf. I agree to indemnify and hold the City of Shafter, its officers, directors, agents, employees, representatives and volunteers free and harmless from any loss, liability, damages, costs, or expenses. I further represent that I am the legal guardian for the minor. I also give permission for the SLC to use pictures or video of my student in promotional materials. I grant permission for my child to use computers, internet and online programs for educational purposes while under the supervision of Learning Center staff. I understand that The SLC will only provide direct supervision for my child during the class time(s) for which my child is registered. At their scheduled release time it is my responsibility, as the parent/guardian, to arrange and ensure transportation home. I understand that it is not the responsibility of The SLC to verify or arrange my child's transportation. Should my child require an early pick up by someone other than those listed on this form a note signed by the parent/guardian is required. I also authorize the SLC to contact me via the contact information I have provided through individual and automated communication.
I understand that the Shafter Learning Center expressly disclaims any liability or responsibility arising from access to our use of information obtained through its electronic information systems, or any consequences thereof. I also grant permission for the Shafter Learning Center to allow my child access to computers with filtered internet AND (please select one):
Many of our courses utilize Khan Academy. We understand that students sometimes forget their Khan Academy login information. Please provide their login information below so that we may be able to assist them and be able to track their progress. In cases where students do not have this information we will gladly create an account for them.