Coffee Time Permission

Coffee Time Permission Form

Purpose: This form allows the student to leave campus unsupervised during the school day with permission from his/her parent as well as his/her teacher.

Process:

- A student with Coffee Time Permission must ask verbal permission from his/her instructor in

order to leave campus for a pre-determined amount of time.

- The teacher may deny permission. This is not negotiable. Disrupting the class to ask, or

debate, permission is unacceptable.

- Each time the student leaves for Coffee Time, he/she must sign out at the front desk with the

teacher’s name that granted permission and the time the student is leaving and will be

returning.

- The student is to leave and return directly without disrupting the learning environment of

others.

- Students on Coffee Time must uphold the rules of the Trillium Constitution, the Trillium

Community Relations Policy, as well as Portland Public Schools policies during this time.

This includes taking part in all emergency procedures such as lock-downs or fire drills.

- Consequences for violating this agreement may include parent notification, loss of Coffee Time

Permission, and/or referral to the OVRR system.

By signing below, the parent/guardian gives permission for the student to leave campus unsupervised during the school day as long as the student has permission from his/her teacher to do so, and follows the rules above.

By signing below, the student recognizes that Coffee Time Permission is a privilege that can be revoked by the parent, teacher, or advisor, if it is abused. The student agrees that he/she must abide by all of the rules above in order to maintain this privilege.

Student Name: ________________________________________________

Student signature: _____________________________________________ Date: _________

Parent/Guardian Name: _________________________________________

Parent Guardian Signature: ______________________________________ Date ________