Student Release Authorization
Our students' safety is the top priority as Jessie Clark Middle, and this includes how we release students for early dismissal.  Students will only be released to the parent/guardian in Infinite Campus or the extra people the parent/guardian includes in this Student Release Authorization.

Using the sections below, please list the people permitted to pick up your child from Jessie Clark.  
This list should include yourself, any parent not in the household, step parent(s), relatives, friends or neighbors to whom you give permission to pick up your child.  We cannot release a child to anyone under the age of 18.  

If you have more than one student who attends here, please list both student names in the "Student Name" section or complete two separate forms.

***  The person picking up your child  MUST BE included on this form or in Infinite Campus for your child to be released. ***

Once completed, it will be made part of your child's record.  Please remember ..... a PHOTO I.D. is required when picking up your child.

Sincerely, 
Jennifer Kendall                       Cassandra Cowan
Principal                                     Attendance Clerk

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Email *
Student's  Last Name: *
Student's First Name *
Parent/Guardian's name: *
I, the parent/guardian do hereby authorize the personnel of Jessie M. Clark Middle school to release the above named student to the following person(s).

Please answer in Name, Relationship to student, Home/cell # format.  (Example:  Aaron Judge, uncle, 859-333-3333)
I, the parent/guardian do hereby authorize the personnel of Jessie M. Clark Middle school to release the above named student to the following person(s).

Please answer in Name, Relationship to student, Home/cell # format.
I, the parent/guardian do hereby authorize the personnel of Jessie M. Clark Middle school to release the above named student to the following person(s).

Please answer in Name, Relationship to student, Home/cell # format.
I, the parent/guardian do hereby authorize the personnel of Jessie M. Clark Middle school to release the above named student to the following person(s).

Please answer in Name, Relationship to student, Home/cell # format.
I, the parent/guardian do hereby authorize the personnel of Jessie M. Clark Middle school to release the above named student to the following person(s).

Please answer in Name, Relationship to student, Home/cell # format.
A copy of your responses will be emailed to the address you provided.
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