Change of Dismissal

Date of Change of Dismissal

Student's First Name

Student's Last Name

Grade

Teacher Name

Select reason for change in dismissal - Select -My child will be an Early Dismissal (in notes section below include reason, TIME, and name of person picking up)My child will go home with friend on different bus (in notes section below include friend's name and bus #)My child will go home with friend via Kiss and Ride (in notes section below include friend's name) My child will attend after-school activity (in notes section below identify after-school activity) My child will go home via Kiss and Ride with parent/guardianMy child will go home with via Kiss and Ride with NON parent/guardian (in notes section below include name of person picking up) My child will walk home to our houseMy child will walk home with friend (in notes section below include friend's name) Other (in notes section below include details for change in dismissal)

Notes Section - for details if requested in parentheses above (If picking student up, please indicate the TIME of pickup)

Parent/Guardian First Name

Parent/Guardian Last Name

Phone Number

Parent/Guardian Email Address

Leave this field blank