Extension / Waiver Form

Participant______________________ Grade ______ School _____________

Address _______________________________________________________

Student # ______________Current Sport/Activity: Port Angeles Track & Field

Today’s Date ______________ Current Amount Due ___________________

Parent/Guardian Name _________________________ Phone _____________

(Please Print)

Payment Schedule (please check all that apply):

____ I will pay amount due in 2 installments. ____ I can pay one half, and request a scholarship 1^st ____________ application.

(Date)

2^nd ___________ Other: ___________________________________

(Date)

_________________________________________

____ I will pay in full by ____________ _________________________________________

Signatures: ___________________________________ __________________________________

Participant Athletic Director

___________________________________ __________________________________

School Office Parent/Guardian

Procedures:

· Extension form is used in place of payment.

· Completion of the extension form will maintain eligibility.

· Extension form must be submitted prior to first contest.

· Extension form should be submitted to the ASB office upon completion.

· Extension form is not complete until each section has been filled out and signed by all parties.

· Scholarship applications are only accepted after completion of extension request.