1. education
2. alumni and reunions

Centralia High School Prom Guest Permission Form
2100 E. Calumet, Centralia, IL 62801
Phone: (618) 532-7391 Fax: (618) 532-8952
Event: Centralia High School Prom
Date of Event: April 18, 2015
1. This form must be filled out, signed, and returned to Mrs. Jack or Mrs. Shipley in the cafetorium
during ticket sales on March 30th – April 1st during lunch hours.
2. If the guest is a CHS freshman/sophomore student, fill out Part I and Part II only.
3. If the guest is a current high school student from another district, fill out Part I, Part III, and Part IV
only. In addition, administrative approval is required.
4. If the guest is not currently enrolled in high school, fill out Part I and Part IV only. In addition,
administrative approval is required.
Part I: (To be completed by the CHS junior/senior student)
Junior/Senior Centralia High School Student (please print): _________________________________
Guest Name (please print): _________________________
Is this guest a present CHS student?
Yes
No
If yes, please fill out Part II. If no, please fill out Part III
Is this guest a former CHS student?
Yes
No
If yes, what years? _______________________
Part II: (To be completed by the CHS freshman/sophomore student and the parent/guardian)
We, the undersigned, have read the rules and policies concerning Prom and do hereby agree to abide
by them.
I find the above mentioned guest to be a responsible person. I approve him/her as an acceptable
guest for this Centralia High School event.
_______________________________
(Parent/Guardian Signature)
_____________
(Date)
_______________________________
(Junior/Senior CHS Student Signature)
_____________
(Date)
____________________________
(Phone Number Required)
Part III: (To be completed if the guest attends another high school)
Guest’s Administrator’s Recommendation:
_________________________ is a student in good standing at ______________________________
(Student’s Name)
(Name of School)
_________________________
(Signature of Administrator)
_________________________
(Title)
_____________________
(Date)
Part IV: (To be completed by all guests who do not attend Centralia High School)
I agree to obey all rules and regulations set forth by Centralia High School concerning this extracurricular event (see below). I understand that I must be no older than 20 years of age and that I
must show a picture ID to enter the event. I also understand that any violation of event
expectations will result in dismissal from the event without refund.
_____________________________
(Guest Name – Please Print)
______________________________
(Guest Signature)
_______________
(Date)
The Centralia High School Administration reserves the right to decline the request of any nonCHS student.
____ Approved
______________________________________
(CHS Administrator’s Signature)
__________________
(Date)
____ Declined
Rules and Expectations for Participation at the Centralia High School Prom
♦
A fully completed Prom Permission Form must be turned in by the required date and time.
♦
Guests must not attend grade school or middle school.
♦
Guests must not be over 20 years of age.
♦
Guests must present a valid picture ID upon entering the dance.
♦
Participants may not be under the influence of drugs or alcohol while attending the dance.
♦
Participants may not be in possession of or use tobacco products while attending the dance.
♦
Participants will not be allowed to return to the dance once they have left the dance facility.
♦
Dress must be appropriate to the occasion. The CHS administration has the right to refuse entry to any
individual that fails to wear appropriate attire.
♦
Hats or headgear will not be worn at Prom.