2018-19 GRASSFIELD HIGH Parking Pass Application
This application is for registering a vehicle by Junior and Senior students enrolled at Grassfield High School for the purpose of securing a parking decal.

Rules and regulations pertaining to on-campus parking and operation of vehicle are contained herein. Completion of this
application shall be construed as acceptance of the parking and operation rules and regulations. Students who elect to drive a vehicle shall complete this application form. Information regarding the sales of permits are included at the conclusion of the form.

Students who are not able to obtain a parking permit prior to opening day should not drive to school. These students should see a security monitor to process their application on the first day. Students must have a parking permit PRIOR to parking on school property. Parking permits will be sold until the predetermined supply is exhausted.

Student Name *
Last Name, First Name
Your answer
Student Grade Level *
Choose one
Student Number *
Your answer
Student's Home Address *
Street Address - Only specify your city if you do not live in Chesapeake, VA
Your answer
Student Phone Number *
Your answer
Parent Information
Required information below must be accurate and complete to secure a student parking permit.
Parent 1 Name *
Your answer
Parent 1 Phone primary phone or Cell number *
Your answer
Parent 1 Work Phone #
Your answer
Parent 2 Name
Your answer
Parent 2 primary or Cell number *
Your answer
Parent 2 Work number
Your answer
Car Information - Vehicle #1
Please provide us with the make and model of the automobile the student will drive to school.
Car Make *
Example: Ford Fusion
Your answer
Car Color *
Your answer
Year the Car was made *
ex: 2005
Your answer
License Plate *
Your answer
Car Information - Vehicle #2
Please provide us with the make and model of any additional automobiles the student will drive to school. Please note: If a student needs to register a second vehicle, there is an additional $20.00 cash fee. (all parking permits are $20)
Car Make
Example: Ford Fusion
Your answer
Car Color
Your answer
Year the Car was made
ex: 2005
Your answer
License Plate
Your answer
Dates/Times Permits will be sold at Grassfield High School (Auditorium)
Seniors (ONLY)
• Tuesday, July 31 (9:00 AM – 12:00 PM) & (2:00 PM – 4:00 PM)
• Tuesday, August 7 (9:00 AM – 12:00 PM)

Juniors (ONLY)
• Tuesday, August 7 (2:00 PM – 4:00 PM)
• Tuesday, August 14 (9:00 AM – 12:00 PM)

Leftover Sales (Juniors and Seniors)
• Tuesday, August 14 (2:00 PM – 4:00 PM)

Please remember to bring the following to school when you purchase your parking permit:
1. Completed and Signed Parking Permit Agreement (available on the Grassfield High School main webpage)
2. A valid VA Drivers' License (for verification purposes)
3. CASH Payment ($20 for each pass)
4. Satisfaction of all student debt/obligations, including class dues from previous school years and current year ($5/year at Grassfield High School)

Also...you must have submitted this form prior to purchasing a permit!

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