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__________________________(Last Name)
__________________________(First Name)
_________________________________: H
_________________________________: W
(Home Telephone)
(Work Telephone)


  1. Read the activity instructions before attempting any laboratory procedure.
  2. Long hair must be tied back when working in the laboratory.
  3. NO "horseplay" or "fooling around" is permitted.
  4. NO optional or original experiments may be conducted without prior approval or adult supervision.
  5. Do not taste any chemicals.
  6. Do not pour any unused chemicals back into stock bottles.
  7. When heated, test tubes should be pointed so the open end is not aimed at anyone.
  8. Broken glass should immediately be cleaned up and discarded into the container labeled for that purpose.
  9. Wash the laboratory table surface after you have finished the activity.
  10. Clean all equipment and return it to the storage area before leaving the laboratory work area.
  11. Report any accident or injury to the instructor immediately, then follow emergency procedures as necessary.


Education Law requires that students wear approved eye safety devices (goggles) whenever instructional programs involve the use of hot solids or liquids, caustic or explosive materials, and certain tools or machinery. In short, goggles must be worn in the laboratory at all times except when specifically told by the instructor that they are not needed.

This is to certify that I have read the "Laboratory Safety Acknowledgment Form" and have been given ongoing verbal instructions from the classroom science instructor concerning safety procedures. I realize that failure to observe these instructions could result in serious injury to others and myself and acknowledges my responsibility towards the care to be used in handling all materials and equipment.

In order to avoid damage to equipment and injuries to others, and myself I promise to observe and obey these rules at all times.

If I neglect these safety rules I understand I may be removed from the laboratory portion of the course.

(Student signature & date)
(Parent/Guardian signature & date)

No lab work may be completed until both student & parent sign this form.

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