PLYMOUTH PUBLIC SCHOOLS

PILGRIM SCIENCE FAIR

Chemical Release Form

Student _______________________ Course ____________________

Teacher _______________________

I requested the following chemicals for my childís science project:

Cost: Chemical Name: Amount: Hazard:

$_______ ______________________________ _____ _____________________

_______ ______________________________ _____ _____________________

_______ ______________________________ _____ _____________________

_______ ______________________________ _____ _____________________

_______ ______________________________ _____ _____________________

_______ ______________________________ _____ _____________________

_______ ______________________________ _____ _____________________

_______ ______________________________ _____ _____________________

$______ Total Cost

I have been informed of the proper handling procedures and special hazardous qualities of each of the above chemicals. I will supervise my child in their use and disposal. I will NOT hold the school authorities LIABLE in the event of injury caused by any of the above chemicals. I also agree to pick up the requested chemicals at school and transport them home in my personal vehicle.

Date_____________________ Signature _________________________________

(Parent/Guardian)