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Preschool Dismissal Form
Child's Name *
Your answer
Grade *
(For 12:30 Dismissal) My child will be picked up with a sibling or other child on the following days (please check all that apply).
Please list other students in 12:30 carpool (including siblings)
Your answer
(For 12:30 Dismissal) My child will be picked up singly (without other children) on the following days (please check all that apply).
(For Later Pickup) My child will attend Lunch Bunch (3:00 p.m. pickup) on the following days (please check all that apply).
(For Later Pickup) My child will attend Gingerbread (pickup open until 6:00 p.m.) on the following days (please check all that apply).
Please list all adults who are authorized to pick up this child, including parents.
Authorized Adult #1 (First Name, Last Name, Phone Number)
Your answer
Authorized Adult #2 (First Name, Last Name, Phone Number)
Your answer
Authorized Adult #3 (First Name, Last Name, Phone Number)
Your answer
Authorized Adult #4 (First Name, Last Name, Phone Number)
Your answer
Is there any other dismissal information you would like us to know?
Your answer
By entering your initials in the box below, you are effectively providing your signature. *
Your answer
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