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Date:
District or Grantee Name:
Site Name: (Example: ASES or 21CCLC and the program name)
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Student NameTime Student Signed InTime Student Signed OutAuthorized Parent/ Guardian
Print Full Name
Authorized Parent/Guardian Signature Required Reason for early pick up? Select from reasons below: (Must be consistent with program's board approved early release policy).
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1. Parallel Program4. Child Accident
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2. Family Emergency5. Safe Transportation Home
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3. Medical Reasons
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John Doe2:45 PM5:15 PMJane DoeJane Doe
Please circle below the reason for early pick up.
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