2025-26 Early Pick Up Request Form/ Formulario de Solicitud de Recogida Temprana

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This form must be completed by the parent/guardian. The adult picking up the student must come into the office with their photo ID./ Este formulario debe ser completado solamente por el padre/guardian. El adulto que recoga al estudiante debe pasar a la oficina con su identificacion.

Student(s) Full Name/ Nombre completo del(de los) estudiante(s) *

Grade/ Grado *

Date and time you plan on picking up the student(s)/ Fecha y hora en que planea recoger al(los) estudiante(s) *

Reason for early pick up/ Razón de recogida temprana *

Illness (i.e. contagious illness/disease, diarrhea, vomiting, fever)/ Enfermedad (i.e. enfermedad contagiosa, diarrea, vómito, fiebre)

COVID positive or exposure/ positivo o expuesto a COVID

Mental health day/ Dia de salud mental

Student Medical or dental / Cita medica o dentista

Transportation issue/ Problema de transporte

Vacation (going out of town or family is visiting)/ Vacaciones (salir de la ciudad o familia viene de visita)

Other:

Full name of adult picking up student(s)/ Nombre completo del adulto que recogera al(a los) estudiante(s)

This adult MUST be on the emergency contact list otherwise they CANNOT pick up the student(s). Updates to the emergency contact list need to be done IN PERSON by the student's parent/guardian./ Este adulto NECESITA estar en la lista de emergencia o no podra recoger al(los) estudiante(s). Actualizaciones de la lista de contacto de emergencias deben ser realizadas EN PERSONA por el padre/guardian del estudiante.

Do you confirm that the aforementioned adult is on the emergency contact list?/ ¿Usted confirma que la persona antes mencionada esta en la lista de contactos de emergencia?
*

Yes/ Si

No, but I spoke with Roosevelt Middle School staff and granted them permission to make a ONE-TIME exception to dismiss my student to the aforementioned adult./ No, pero hable con el personal de Roosevelt Middle School y les otorgue permiso para hacer una excepcion UNICA para despedir a mi estudiante al adulto antes mencionado.

Parent/guardian Full Name/ Nombre completo del padre/guardian *

Parent/guardian phone number/ Numero de telefono del padre/guardian *

Parent/guardian email address/ Correo electronico del padre/guardian *

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