Permission for Student Self Dismissal
Email address *
Name of Student(s): *
Your answer
Class/Teachers: *
Guardian’s Cell#: *
Your answer
Guardian's Email:
Your answer
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) *
Your answer
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. *
Today's date *
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