Mother, may I?

Due to the recent clogging problems in our bathrooms, I have come up with a form that our children will be required to fill out before using the restroom.


Restroom use requisition form
Form must be completely filled out before submitting for approval.

NAME_____________________

Location of restroom requested______________
2nd choice__________
(Please remember that Mom and Dad’s bathroom is off limits.
Please do not request. You will be denied)


What will you will be using the restroom for?
(circle all that apply)
#1
#2
Other - Please explain_______________________
________________________________________

On the back of this paper, please list everything
you have eaten in the last 24 hours.
Please highlight any items that might cause constipation,
and circle all high fiber foods.

When was the last time you used the restroom?
Date_________
Time_________
Length of visit______hours______minutes

Did you have any difficulty with that particular trip?
If yes, please explain.________________________
__________________________________________


Please list the approximate amount of toilet paper
used in your last trip to the restroom.
________________squares.


Give an estimate of the amount of toilet paper
you think you will need for this next trip.
________________squares
________________rolls


Do you have a physical disability that might prevent
you from turning on the fan in the restroom?

Have you ever flushed a non flushable item?____________

If yes, please list the item, and date of the illegal flushing.
Please include a detailed essay, outlining reason why you felt the need to flush said object.
( you may use the back of this form if needed)

Are you on the restroom cleaning schedule?________
Do you have a physical disability that might prevent
you from using a plunger?

Have you ever been responsible for a clogged toilet that
resulted in the toilet spilling water onto the bathroom floor?
Please explain___________________________________
_______________________________________________



(Boys only)
Are your arms broken in such a way as to prevent you
from lifting up the toilet seat?___________

When aiming, what is your percentage of accuracy?_______%
_______________________________________________________

Please fill out the form completely.
Incomplete forms will not be processed, and will result in automatic rejection.

Submit completed forms along with two references,
and a photo ID to Mom or Dad.
(Grandma can approve if Mom or Dad are not available)
Forms will be processed on a first come first served basis.

Please plan ahead. Any accidents due to insufficient notice,
will be noted, and may result in difficulty to be approved
at a later date.
Signature of applicant_________________
____________________________________________________
For office use only:

Approved
Denied
Send to service station

Approval signature________________________



Please let me know if I forgot anything.