Student Name: ____________________________         Date: ____________

Please complete the following request information and return to the High School Counseling Office for approval.  

Type of Request: (please circle one)        Late Arrival                Early Dismissal

Requested periods for early dismissal/late arrival: Periods_______________________________________________________________

As per building procedures, students who are seniors may come late to, or be released early from school.  Each student must comply with the minimum requirements listed below:

• Students must maintain passing grades in all classes throughout the entire school year.
• Students must maintain acceptable attendance rates.
• Be on track with proper credit to graduate, including exams.
• Attend classes as scheduled.
• Maintain proper & acceptable school conduct.
• Students must follow their original schedule until notified of the request being approved.  
• Students must sign in/out at the Attendance Office upon arrival and dismissal from school.
• Must have consistent transportation arrangements.

**At any time the student is not adhering to the above requirements, their privileges may be revoked at the discretion of administration.

Student Signature: _______________________________________  Date: _____________

Parent Signature: ________________________________________  Date: _____________

Counselor Review:

My Signature verifies that I have reviewed this student’s record; this student meets the requirements and has earned this privilege.

Counselor Signature: ______________________________________  Date: _____________

CC: Attendance, Student File