Heartland Charter School
Supervision Waiver
As the parent or legal guardian of
Student Name & Local ID
I understand that I am responsible for overseeing my students use of the following item
Item Name
Vendor (if applicable)
Vendor name
I agree to supervise my student and accept responsibility on my child's behalf for any liability
Parent Name
Parent Signature
Date
/
Month
/
Day
Year
Date
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