Supervision Form

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

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Please select your HST from the dropdown
Should be Empty:

Supervision Waiver