Fourth and Fifth Grade Independent Walker/Biker Permission Form
Please fill out this form if you wish to give permission for your child to walk/bike home from school. By completing this form, you indicate your understanding that you are authorizing your child (listed below) to walk or bike home from school independently. Please note that this permission slip grants permission for this child to leave school without adult supervision. Students may walk home or bike home only if this form is completed. If we do not have this form completed, your child will not be released without authorized adult supervision.

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Student Last Name: *
Student First Name:   *
Homeroom Teacher: *
Fourth and Fifth Graders Must Read:
Walking to and from school is a big responsibility. You must follow the rules of both the school and the rules as a pedestrian. You are never to walk on the road. You are to walk on the sidewalk or on the grass a minimum of 15-20 feet from the road. You may only cross the road at intersections and must take special care to look both ways several times before crossing. Remember that the simple fact that you can see a vehicle does not guarantee that you are visible to the driver of a vehicle. Remember that any irresponsible behavior exhibited while walking home can result in the loss of walking privileges. Please be responsible and careful! I have read the paragraph above and agree to be responsible and careful.
Younger Siblings: Please list the names and homeroom teachers of any younger siblings who you give permission to walk independently with your fourth/fifth grader.
Parent/Guardian Signature: (Please type name) *
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