This form WILL NOT be accepted at the door the night of the dance!

Millard North High School Dance Permission Form
For NON-MILLARD NORTH Guest of Millard North Student – Prom - March 28, 2015
 Guest should be in high school and/or under the age of 21; the Guest must complete Box A and sign.
 IF Guest is a current high school student, an administrator from his/her school must complete Box B and
fax signed form to MNHS (Fax: 715.1336).
 The completed form must be returned to Millard North by Thursday, March 26, 2015.
 Millard North students may bring only one (1) guest.
Millard North Student Name: _________________________ Grade:______ID#__________
Box A – To be completed by Guest:
Name: ____________________________________ Age: ___________ Date of Birth: ____________
Home Address: ____________________________ City: ____________________ State: ___________
Home Phone: ______________________________ Alternate Phone: ___________________________
IF PREVIOUSLY GRADUATED: SCHOOL_______________________________YEAR_______________
Parent/Guardian Name:_________________________________________________________________
** No lewd or provocative dancing will be allowed. Students who are found in violation of this rule
will be told to leave the dance. There will be no warning given. ** (An administrator or designee at
the dance will determine what is lewd and/or provocative.)
I, __________________________________ (Guest), agree to obey all rules and regulations set forth by
Millard North High School concerning student attendance at extracurricular events.
Guest MUST present a SCHOOL PHOTO ID/PHOTO ID at the door the night of the event
Signed (Guest): _____________________________________________ Date: ____________________
Box B – To be completed by an Administrator of the Guest’s home high school:
Name of School:____________________________________ School Phone:_________________
Is the above-named student currently in good standing?
YES
Do you recommend that he/she be admitted to the MNHS Homecoming Dance? YES
NO
NO
** The Guest’s School Administrator must fax this form to Millard North at 402-715-1336 **
School Administrator Signature and Title:__________________________________________________
Please print name here: __________________________________________________
This form WILL NOT be accepted at the door the night of the dance!
Millard North Fax – 402.715.1336
Attention: Chad Zimmerman, Millard North HS Activities Director