Dismissal Change Form

Student's Name Student's Name First Last
Classroom
My Child will....
On the following day: On the following day: / MM / DD YYYY
Time of late arrival or early pickup: Time of late arrival or early pickup: : HH MM AM/PM
Please provide the reason, details and any necessary additional information regarding your child's absence, tardiness, early pick-up, or change in dismissal routine:
Parent's Name Parent's Name First Last
Parent's E-mail
Parent's Phone Parent's Phone - ### - ### ####
Parent's Signature:

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Type the letters you see in the image below.