Request for Temporary Change of Dismissal Change

Complete this form PRIOR to 3:15pm if you need to change your child's dismissal. No changes will be made after this time.

**CHANGES SHOULD NOT BE MADE ON A DAILY BASIS!!**

Student Name Student Name First Last
Teacher Name Teacher Name First Last
Student Name #2 Student Name #2 First Last
Teacher Name #2 Teacher Name #2 First Last
Student Name #3 Student Name #3 First Last
Teacher Name #3 Teacher Name #3 First Last
Beginning Date Beginning Date / MM / DD YYYY
Ending Date Ending Date / MM / DD YYYY
Student's Normal Dismissal

Student's Normal Dismissal Car Rider Bus Rider Walker/Bike Rider Daycare Van
NEW DISMISSAL

NEW DISMISSAL Car Rider Bus Rider *must have a bus pass to choose this option Walker/Bike Rider (unescorted- can go without an adult) Walker/Bike Rider (must have an adult meet them to leave school- with ID/Tag) Daycare Van
Name of Daycare Van if applicable Name of Daycare Van if applicable First Last
Name of Person Requesting Change- must be the custodial adult in myStudent Name of Person Requesting Change- must be the custodial adult in myStudent First Last
Email of Person Requesting Change
Contact Number for Questions Contact Number for Questions - ### - ### ####
NO CHANGES ARE PERMITTED AFTER 3:15PM FOR THE SAME DAY DISMISSAL CHANGE

NO CHANGES ARE PERMITTED AFTER 3:15PM FOR THE SAME DAY DISMISSAL CHANGE I AM AWARE THAT CHANGES MADE AFTER 3:15PM FOR THE SAME DAY WILL NOT BE HONORED
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