I, ______________________________(name of child) , on this day ____________________________ (date)

asked to have  my curfew extended from ______________________ (current curfew)   to

(requested curfew).


I am asking to have my curfew extended on _____________________ (date) because I want to
__________________________________ (reason for request i.e. school dance).    I understand that 
his is a one-time extension and that my curfew will remain ____________________
(current curfew) on

all other nights following this event.  I was  informed by ___________________ 
(Mom and/or Dad) 

that should I break this curfew on ________________________  (date of event)  that I will  _____________
(punishment for breaking curfew).     


I understand and agree that I will also need  to __________________________________________
(i.e.: call home, call at a certain time etc.)  in order to be granted an extension
on my current curfew.  I agree to all of these terms.

______________________________         ____________________________             _________
    Childís Signature                                     Parentís Signature                                    Date