CITRUS VALLEY HIGH SCHOOL PTSA
NON-STUDENT GUEST PASS REQUEST FORM GRAD NITE,
JUNE 6, 2015
CVHS Grad Nite Guest Policy: Must be at least a high school senior
and 20 or under. Only one guest per CVHS student.
This form must be completed and returned at the time of the Grad Nite Ticket purchase during March &
April. Please allow at least 2 weeks for processing.
All guests must provide a copy of their current picture ID with this pass.
CVHS student name: ____________________________________________________
Guest information:
Guest name: ___________________________________________________________
Guest age/grade: ________________
ID checked:
Yes _____ No _____
Address:
Street:________________________________________ City:_____________ St.: ______ Zip:___________
Home phone: _____________________________ Cell phone:__________________________
Guest Statement
As a guest of a Citrus Valley High School PTSA sponsored event, I understand that I am under the jurisdiction of all rules that Citrus Valley High
School students MUST follow, including Dress Code. Failure to do so may be grounds for removal from this event. I further understand that I am
subject to all aspects of Redlands Unified School District Policy, the California Education Code, federal, state and local law. **
Guest signature: _____________________________________
Guest parent signature: _____________________________________ (if under 18)
Citrus Valley High School Student Statement:
I AGREE to be responsible for my guest’s actions and adherence to Citrus Valley High School rules.
Citrus Valley High School Student signature: _________________________________________
Parent Statement:
I have reviewed the information provided and can be reached at the number listed below for verification purposes, I understand that three attempts will
be made to reach me at the number I have provided. If personal contact cannot be made, I understand that the guest pass requested by my child will not
be issued.
Citrus Valley High School parent signature: _____________________________________
Citrus Valley High School parent printed name: __________________________________
Phone: ___________________________________
Attempt: #1 _____________________ #2 _____________________ #3 _______________________
Must be read and completed by the guest’s school administrator:
1. The guest is at least a high school senior and a copy of their current photo ID is attached to this completed form.
2. The guest name above is a student in good standing at their current high school and is recommended as a guest at this Citrus Valley High
School PTSA sponsored Grad Nite event.
Signature of administrator from guest’s school: ____________________________________________
Printed name of administrator: _________________________________________ Date: ___________
**NOTE: All persons making the field trip or excursion shall be deemed to have waived all claims against the PTSA, district or the state of
California for injury, accident, illness or death occurring or by reason of the field trip or excursion (Education code: 35330)
CITRUS VALLEY PTSA
School Activities Medical
Release Form
2015 GRAD NITE
DISNEY CALIFORNIA ADVENTURE
DATE: Saturday, June 6, 2015
departing CVHS at 11:00 a.m., returning to CVHS at 4:30 a.m. on Sunday, June 7
**NOTE: All persons making the field trip or excursion shall be deemed to have WAIVED all claims against the PTSA, district or
the state of California for injury, accident, illness or death occurring or by reason of the field trip or excursion (Education code:
35330)
(Retain top portion for your information)
I give my consent for: ___________________________________________________________________________ (Please print name)
To leave Citrus Valley High School at approximately
11:00 a.m. on Saturday, June 6, 2015
And return at approximately 4:30 a.m. on Sunday, June 7 to participate in:
CITRUS VALLEY HIGH SCHOOL
GRAD NITE 2015
DISNEY CALIFORNIA ADVENTURE, ANAHEIM, CA
Students and guests will travel by air-conditioned school bus only between
CVPTSA/CVHS and Disney California Adventure
THE FOLLOWING IS TO BE COMPLETED BY PARENT/GUARDIAN
My student has the following medical problem(s):
__________________________________________
Medications my student will be bringing with them:
____________________________________________
__________________________________________
____________________________________________
In the event of any illness or injury, I hereby consent to whatever x-ray, examination, anesthetic, medical, dental, or surgical
diagnosis or treatment and hospital care from a licensed physician and/or surgeon as deemed necessary for the safety and welfare of
my child (or the individual named above.)
______________________________________________________________________________________________
Date
Emergency Contact Number(s) ________________ __________________
Signature of Parent/Guardian
_________________________
Signature of event supervisor
Student cell phone: ________________________________________
**All persons making the field trip or excursion shall be deemed to have WAIVED all claims against the PTSA, district or the state
of California for injury, accident, illness or death occurring or by reason of the field trip or excursion (Education code: 35330)
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CITRUS VALLEY PTSA
2015 GRAD NITE
DISNEY CALIFORNIA ADVENTURE
June 6, 2015
Student/Parent Contract
I ___________________________________ have read the Dress Code requirements and Rules
and Regulations for Disney California Adventure and will adhere to them during the time I
leave CVHS on Saturday, June 6, 2015 and return on Sunday, June 7, 2015.
I UNDERSTAND that failure to adhere to the Citrus Valley Dress Code policy and the Dress
Code policy of Disney California Adventure will result in delayed or denial of admission into
Grad Nite activities.
I UNDERSTAND failure to comply with the Rules and Regulations WILL result in my
confinement to a designated area and/or be asked to leave. In the event I am asked to leave, it
will be the responsibility of my parent/guardian to pick me up at Disney California Adventure.
______________________________________
Print name
______________________________________ ____________
Signature
Date
______________________________________
Student’s cell phone
______________________________________ ____________
Parent Signature (if student under 18)
Date
______________________________________
Print name
______________________________________
Parent home and cell phone
Dress Code
The Disneyland® Resort aims to provide a fun, safe
environment and an enjoyable experience for all Guests. To
that end, the following are not permitted:
Clothing
or tattoos with obscene, lewd or offensive language,
graphics or designs Clothing that could be construed as
inappropriate for a family environment (e.g., string bikini tops and
bottoms, G-strings, excessively torn clothing) Bare feet Weapons
or accessories that appear to be weapons (e.g., bullet belts) 
Clothing or accessories that drag on the ground or create a potential
tripping hazard Wedding dresses Sharp or pointed accessories
that may cause injury Masks or makeup that could be viewed part
of a costume, with the exception of special events or attire intended
to identify the wearer (e.g., military uniforms, cultural attire)
Dress code is subject to change without notice and will be
ENFORCED!