Countryside Student Pick up Form for Monday, 12/6/21
Please complete this form to notify Countryside that your child or children will be picked up from school today! You DO NOT need to fill out this form if you are picking your child up from daycare.

This Student Pick-up form must be completed DAILY by 11:30 AM.

Please submit this form for each student you plan on picking up.

If you need to pick up your child at dismissal, and this form was not completed by 11:30 AM, please email the student's teacher AND Mrs. Sengdetka at

Thank you!
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Email *
Student Last Name *
Student First Name *
Grade *
Student's Classroom Teacher *
If you are picking your child up BEFORE REGULAR DISMISSAL, WHAT TIME will you be here to pick them up?
Photo ID required upon pick-up. Name of person picking up (as it appears on Photo ID). *
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