2016-2017 Academic Arcade Permission Form

Student Information

Please enter the student's name in the boxes below (LAST, First, Middle):

Teacher: 1st Grade2nd Grade


Is your child allowed to watch:

Entertainment Videos: YesNo
Educational Videos: YesNo


My child does not participate in the following celebrations:


My child is allergic to:


Please Note: For the safety of the children you must have a release pass from the school office to pick your child up from Academic Arcade. Thank you for your cooperation.


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