BEMUS POINT CENTRAL SCHOOL DISTRICT
PARENT PLEDGE 2011-2012 SCHOOL YEAR

-------------------------------------------------------------------------------------------------------------

Please fill out First and Last Names(s) for student(s) during the 2011-2012 school year

STUDENT NAME:

STUDENT NAME:

STUDENT NAME:

Grade

Grade

Grade

School

School

School

Mother/Guardian

Father/Guardian

Address

City

Zip Code

Telephon Number 1

Telephone Number 2

Address (If Different)

City

Zip Code

Telephon Number 1

Telephone Number 2

=========================================================================================================

=========================================================================================================

BEMUS POINT CENTRAL SCHOOL DISTRICT DRUG AND ALCOHOL TASK FORCE invites you to join the Community/Family Network. In creating a network we give ourselves the advantage of knowing who in our community has made a commitment to assisting in the prevention of tobacco, alcohol, and other drug use by our youth. By signing the Network Agreement you agree to:

* Encourage wholesome activities for our youth by chaperoning and not allowing tobacco, alcohol, or any drug to be brought in or consumed by underage youth who are socializing in your home.

* Communicate with the parents and appropriate adults to insure that events outside of your home will be properly chaperoned and will not include tobacco, alcohol, or any other drug by our underage youth

Check ONLY ONE of the appropriate boxes below TO HAVE INFORMATION EXCLUDED from the on-line directory

I DO NOT want my phone number included in the On-line Directory

I DO NOT want my address included in the On-line Direcotry

=========================================================================================================

To verify that a parent or guardian is filling out this form, please insert your name again below and we will match your information up with Powerschool and give you a callback. Thank you.