_____ I have read carefully the Safety Rules.

        I know the location of the following safety equipment:

_____ fire extinguisher

_____ safety shower

_____ eyewash station

_____ safety (fire) blanket

_____ I know the location of the nurse's office.

_____ I know the fire exit routes.

     I agree to abide by the rules and procedures described in the safety rules.  I will also abide by any other rules and regulations provided by my chemistry teacher.  I realize that if I do not abide by the rules I will not be able to participate in the lab activities and therefore will receive a ZERO for a grade on such acivities.  I also understand that depending on the severity of the offense, I may be removed from class until a meeting with my parent/guardian and the administration takes place.

     I understand that I am required to wear safety goggles at all times when directed to do so in the laboratory.  I also understand that there are dangers involved in wearing all types of contact lenses in laboratory situations where fumes may be produce.  I am aware that even when safety goggles are worn, the Science Department strongly discourages the wearing of contact lenses in these situations.  If I do elect to wear contact lenses in the laboratory, I will inform my instructor and I will assume all responsiblilty for damages caused by wearing them in the lab.

     If I have a medical condition with may cause sudden loss of consciousness or allergies/asthma, I certify that I am under a doctor's care and that my doctor has given me explicit permission to participate in this laboratory course.  I will inform my instructor of my condition at the beginnning of the semester, or as soon as I am aware of the existence of the medical condition.

____________________                       ____________________

Student's signature                                      Date

I, as parent/guardian of the above named student, have read and discussed the rules with my child.  I support safe laboratory practices and will insist on complete compliance with the rules.

____________________                       ____________________

Parent's/Guardian's Signature                           Date

Please sign both copies, keep one, and return the second by the date on the top of the page.