DISMISSAL AUTHORIZATION FORM

FAMILY NAME

CHECK ALL BOXES THAT APPLY

CAR POOL

Unless I notify the school otherwise in writing, at the close of each school day, my child/children,

will be picked up at the school no later than 20 minutes after the final bell by

NAMES

CHILD'S NAME HOMEROOM

CHILD'S NAME HOMEROOM

CHILD'S NAME HOMEROOM

CHILD'S NAME HOMEROOM

CHILD'S NAME HOMEROOM

AFTER SCHOOL CARE PROGRAM

My child/children will regularlyoccasionally attend the school's After School Care Program

THE FOLLOWING ADULTS ARE AUTHORIZED TO PICK UP MY

CHILD/CHILDREN

Name Relation Mother Father Grandparent Aunt/Uncle Neighbor Other PHONE# Choose Cell Work Home

Name Relation Mother Father Grandparent Aunt/Uncle Neighbor Other PHONE# Choose Cell Work Home

Name Relation Mother Father Grandparent Aunt/Uncle Neighbor Other PHONE# Choose Cell Work Home

Signature and Date______________________________________________