Work Release Form printable pdf download

CEDAR BLUFFS HIGH SCHOOL SENIOR WORK RELEASE FORM

The student listed below has requested work release from Cedar Bluffs High School. The

student making this request must provide a written request, signed by the parent, to the

principal. The student must be making normal progress toward meeting all graduation

requirements in order to be considered for work release. The student, employer and

parent must fill out this form, and have signed approval by the principal, and guidance

counselor.

The employer shall guarantee employment through the semester and or school year and

sign to that effect.

Student Name: ___________________________________________________________

EMPLOYER SECTION

Name of Business: ________________________________________________________

Address: ________________________________________________________________

Name of Supervisor: ______________________________________________________

Days of the week employed at this location: (circle) M T W TH F

Hours of employment: Start: ___________

End: ___________

(Please provide a weekly schedule, if the schedule varies.) If for some reason the

employer terminates this employee, the student and employer will inform the school

principal or guidance counselor and this agreement shall be null and void.

Signature of Employer: ____________________________________________________

The school may end this agreement if the student ends employment, fails to attend classes

on a regular basis, does not continue to make progress toward meeting graduation

requirements, does not adhere to the work release agreement, or is declared ineligible

under school rules.

Student Signature: ____________________________________ Date: _____________

Parent Signature: _____________________________________ Date: _____________

Principal: ___________________________________________

Date: _____________

Guidance Counselor: __________________________________ Date: _____________

Work Release Form