Permission for Student Self Dismissal
Name of Student(s):
K - Lorrie & Eliza
K- Rebecca & Susan
1st - Rachel & Millen
1st - Sheba & Naveira
2nd - Molly & Jen
2nd - Daina & Blair
3rd - Maggie & Nora
3rd - Chanel & Eden
4th - Hannah & Jamie
4th - Anja & Tiffany
5th - Sophie & Sofia
5th - Flavia & Ellen
The undersigned being the parent or guardian of the above named student(s) give authorization for said student(s) to Self Dismiss without adult supervision at/from: (check all that apply)
Regular Dismissal Time - 3:45 pm Daily (or list specific days in Comments)
Half Day Dismissal Time - 12:00 pm
Afternoon School Bus Daily (or list specific days in Comments)
After School Program Dismissal Time - 6:00 pm – Daily (or list specific days in Comments)
Other times – please indicate specific dates/times in Comments below
I assume full responsibility of said student(s) and I hereby agree to not hold the school, school staff or school bus drivers responsible for any and all liabilities arising from any accident or incident as a result of my student(s)’s travel without adult supervision.
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This form was created inside of Community Roots Charter School.