Request for Temporary Change of Dismissal

Student Name Student Name First Last
Afternoon Teacher's Name
2nd Student's Name 2nd Student's Name First Last
2nd Student's Afternoon Teacher
3rd Student's Name 3rd Student's Name First Last
3rd Student's Afternoon Teacher
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/Biker Daycare Van PLACE
New Dismissal

New Dismissal Car Rider Bus Rider *Must have bus pass to choose this option* Walker/Biker Daycare Van *Please indicate daycare name* PLACE
Daycare Van Name/Additional Notes
Name of Person Requesting Change
Email
Contact Number for Questions Contact Number for Questions - ### - ### ####
No changes are permitted after 3:15pm for same day dismissal change.

No changes are permitted after 3:15pm for same day dismissal change. I am aware that changes made after 3:15pm for same day will not be honored.