Upton Junior School - Leaving school unaccompanied permit request

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Please spare 5 precious minutes to complete this very important form. The safety of your child is the highest priority for us at Upton Junior School. Because of this, we need to know if your child will leave school at the end of the day unaccompanied by an adult. We sincerely hope there isn't ever an emergency regarding the collection of your child but we feel safety measures should always be in place. Children's safety must and always will remain our highest priority!

One Childhood, One Chance!

Child's Name: *

Class: *

Which option below applies to your child? *

My child cycles to / from school unaccompanied

My child walks to / from school unaccompanied

My child leaves the school premises unaccompanied but meets an adult in a designated area

My child leaves school unaccompanied to catch public transport

Required

Please provide further information if appropriate:

Cycling unaccompanied to / from school

If this doesn't apply please go to the next section.

Cycle colour:

Cycle make:

Special Features of bike:

Bike Serial Number:

Lock Serial Number:

Meeting an adult at a designated area outside the school gates

If this doesn't apply please go to the next section.

Where is the designated meeting point?

Estimated time of adult arrival:

Time

Name of person meeting child:

Time child should be advised to walk back to school by:

Time

Details of person completing this form

Form completed by: *

Relationship to child: *

Email Address: *

For confirmation purposes only

Submit

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