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Student Dismissal Form
For students in grades 5-8 who are allowed to pick up younger siblings. Older siblings will exit the building (rain or shine) and walk to the exterior doors to pick up their siblings at 3:01.
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Email
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Your email
1. What grade is your older child in?
*
5
6
7
8
2.
Older Child's name
and
Homeroom
(Example: Peter Parker/Dr. Conner's Homeroom)
*
Your answer
3. What grade is your younger child in?
*
K
1
2
3
4
4.
Younger Child's name
and
Homeroom
(Example: Harold Hutchins/Mr. Krupp's Homeroom)
*
Your answer
(
OPTIONAL
) 5. What grade is younger child #2 in?
K
1
2
3
4
Clear selection
(
OPTIONAL
) 6.
Younger Child #2's name
and
Homeroom (
Example: Carlos Ramon/Ms. Frizzle's Homeroom)
Your answer
(
OPTIONAL
) 7. What grade is younger child #3 in?
K
1
2
3
4
Clear selection
(
OPTIONAL)
8.
Younger Child #3's name
and
Homeroom
(Example: Matilda Wormwood/Ms. Honey's Homeroom)
Your answer
9.
Do you give permission for your older child to exit the building at 2:56 and walk around the outside of the building to pick up your younger child?
*
Yes
No
10. Please enter your phone number:
*
Your answer
11. Please type your first & last name as a signature to confirm all of the above information:
*
Your answer
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