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288 West Santa Monica Avenue, Dededo, Guam 96929

Phone: (671) 632-5647


Accredited for six years by WASC and an active member of Learning School Alliance
Website: http://www.gdoe.net/vsabms
Email: vsabms@gdoe.net
Jon J. P. Fernandez Patrick Flores Egrubay
Superintendent of Education Principal

FOOD WAIVER AND RELEASE FROM LIABILITY


Dear Parent / Guardian,
Your childs teacher, class, team, and/or club may sponsor an activity, field trip, or event wherein food that is prepared by or purchased
from an approved outside vendor or food that is prepared as part of a learning activity (such as in home economics or cultural classes) will be
consumed. By signing below, you are giving your consent for your child to participate in such activities or events and hereby release V.S.A. Benavente
Middle School, its employees, representatives, and/or affiliates from any liability resulting from the consumption of said food or allergic reactions
thererof. By signing below, you further agree that V.S.A. Benavente Middle School, its employees, representatives, and/or affiliates shall not be
responsible, in any manner, for any claim, cost, losses, liabilities, illness, expenses, or other damage arising from the consumption of said food or
allergic reactions thereof. Please initial Sections A and B, and then sign Section C below.

SECTION A: FOOD WAIVER


Please place your initials on the appropriate line. Select only one choice in this section.

__________ Yes, I am giving consent for my child to participate in activities, field trips, and/or events where there will be consumption of
food. I hereby release V.S.A. Benavente Middle School, its employees, representatives, and/or affiliates from any liability resulting
from the consumption of said food or allergic reactions thereof. I further agree that V.S.A. Benavente Middle School, its
employees, representatives, and/or affiliates shall not be responsible, in any manner, for any claim, cost, losses, liability, illness,
expenses, or other damage arising from the consumption of said food or allergic reactions thereof.

__________ No, I do not want my child to participate in activities, field trips, and/or events where there will be consumption of food. I do not
wish my child to consume food that is prepared by or purchased from an approved outside vendor or food that is prepared as
part of a learning activity.

SECTION B: FOOD ALLERGY INFORMATION


Please place your initials on the appropriate line. Select only one choice in this section.

__________ No, my child does not have any food allergy, life-threatening or otherwise.

__________ Yes, my child has a food allergy. My child is allergic to _____________________________________ and may not consume this
food or any product or dish that contains this food allergen.

SECTION C: PARENT/GUARDIAN & STUDENT ACKNOWLEDGEMENT


Please print clearly and sign.

Students Name: _______________________________________ Signature: ________________________________ Date: __________

Parent/Guardians Name: ________________________________ Signature: ________________________________ Date: __________

Homeroom Teacher: ____________________________________ Team: ___________________________________ Room #_________

_________________________________________________________________________________________
Dennis Malilay Maria Milan Eric Dela Cruz Maylene Wolford
6th Grade Administrator 7th Grade Administrator 8th Grade Administrator Administrative Officer

Vision: Students will have excellent character, lifelong desire for learning, ingenuity and perseverance to solve personal and global problems,
and passion to serve their community.
Mission: Our mission is to provide a safe, supportive, and progressive learning environment that enables our students to achieve at the highest levels
and empowers them to be innovative and productive as they face the challenges of the future.

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