Work-Based Learning Program
Early Release Understanding and Insurance Verification Form

School  	

WBL Program   	

School Contact   	

Directions:  For a student to be enrolled in the program, the parent/guardian must provide the required information below and sign and date the form at the bottom of the page.

Early Release

I understand that my child,

, is enrolled in the work-based learning program at
High School and that my child will be dismissed from school at the end of his/her regularly

scheduled on-campus classes each day.

I assume full responsibility for my child after dismissal from school, including days when my child is not required to be on the job. I also understand that my child must be covered by automobile accident and health insurance in order to drive to and from work and to be a part of the work-based learning program.  (please complete information section below).

Automobile Accident and Health Insurance

I understand that my child must be covered by automobile accident and health insurance to participate in the work-based learning program.  I have checked the appropriate statement regarding insurance coverage for this school year.  I agree to notify the work-based learning coordinator if this coverage changes during the school year.

Automobile Accident Insurance
  Other Mode of transportation
  My child is covered by automobile accident insurance through the following provider:

Provider
Address
Name of Insured

Health Insurance
	No Health Coverage
or

Policy Number City, State, Zip Phone Number

	My child is covered by health insurance purchased through the school or
	My child is covered by health insurance through the following provider:

Provider
Address
Name of Insured

Policy Number City, State, Zip Phone Number

Parent’s or Guardian’s Signature	Date