This form is to be completed each time access is requested and is limited to that specific occurrence unless otherwise noted below, and must be submitted three (3) school days in advance to the applicable building Principal or Superintendent. 

Name___________________________________ Date of Request________________________

Date of Birth (Month/Day/Year)________________      Gender (circle one)     Male    Female

Home Address _________________________________________________________________

Phone Numbers_________________________________________________________________

                                Home                                       Cell                                          Work

E-mail address ________________________________________________________

Date(s) Requesting to be on School Property_____________________________________________

Time of Day Requesting to be on School Property_________________________________________

Name of School/Building or Location on School Campus________________________________ 

______________________________________________________________________________________

Access shall be limited to the building and/or location noted herein, the parking lot and sidewalk/public access to the building or location designated herein. 

State the specific reason/nature of the request to come upon school property_______________ 

_____________________________________________________________________________________

  *   *   *   *   *  

If request is related to your employment, provide the following information: 

Current Employer __________________________________________________________________

Years Employed ___________     Name of Immediate Supervisor _________________________

Supervisor’s Phone Numbers _________________________________________________________

                                                Work                                                    Cell

Applicant may NOT come on school property until applicant has received this form indicating approved by the Superintendent and access shall be limited as indicated below. 

Signature below indicates the information provided herein is true and accurate and requesting party is in full compliance with all Wyoming statutes regarding registered sex offenders. 

___________________________________________                     _______________________________

            Signature                                                                     Date

**SCHOOL USE ONLY**                                                                                                           

Form Submitted to: 

Principal/Superintendent Name____________________________   Building________________

Date Form Received ____________________________________

Limitations/Expectations for Access_________________________________________________ 

______________________________________________________________________________

This request is ___ Approved    ____ Denied

______________________________________                              ____________________________

Superintendent Signature                                                                    Date

Revised 8/28/12