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I request that my child, identified below, be authorized to possess and use a cellular telephone while on premises owned, rented, or under the control of the Trevor-Wilmot Consolidated Grade School District. I request that my child be authorized to possess and use a cellular telephone for the following reason( s ):

Medical reasons: Explanation:
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School related or educational reasons: Explanation:
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Work or vocational reasons: Explanation:
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Other reasons: Explanation:
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I understand and agree, as does my child, that possession and use of a cellular telephone while on District premises is subject to school rules. Both my child and I have received, read and understand and agree to follow District rules governing the use of cellular telephones.

Name of Student _________________________________________________________
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Name of Parent __________________________________________________________
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Signature of Parent _______________________________________________________

_____ Approved _____Disapproved

Administrator Signature ______________________________________________________

Administrator Name (Typed or Printed) __________________________________________