DISMISSAL PROCEDURES 2011/2012
(Please print clearly)
Student’s Last Name: / Student’s First Name: / Grade: / Teacher:
Parent/Guardian’s Name(s):
Mother’s Phone Nos:
Home: Cell: Work:
Father’s Phone Nos:
Home: Cell: Work:
My child’s normal dismissal routine from school is as follows (check ALL that apply):
[ ] Picked up at school by parent/guardian
[ ] Picked up at school by family member (i.e., sibling, grandparent, etc.) indicated below:
1.______
Name Relationship
2. ______
Name Relationship
3.______
Name Relationship
4.______
Name Relationship
[ ] Picked up at school by family friend indicated below:
1.______2.______
3.______4.______
[ ] Meets a family member at a location on school grounds other than assigned dismissal door.
[ ] Takes the school bus home.
[ ] Attends the FSP Y school-age child care program on the following day(s) of the week:
[ ] Monday [ ] Tuesday [ ] Wednesday [ ] Thursday [ ] Friday
[ ] Attends the JCC after-school program on the following day(s) of the week:
[ ] Monday [ ] Tuesday [ ] Wednesday [ ] Thursday [ ] Friday
[ ] Walks home alone.
[ ] Other (please provide specific details on space provided):
Parent/Guardian’s Signature: Date:
SCHOOL ONE
DISMISSAL PROCEDURES 2010/2011
Student’s Name Grade Teacher
Parent/Guardian’s Name:
Parent/Guardian’s Phone Number(s)
My child’s normal dismissal routine from school is as follows:
q Picked up by parent/guardian
q Picked up by indicated family member (i.e., sibling, grandparent, etc.):
q Picked up by indicated family friend:
q Meets a family member at a location on school grounds other than assigned dismissal door
q Takes the school bus
q Attends the [ ] FSP YMCA school-age child care program, or [ ] JCC after-school program on the following days: [ ] Monday, [ ] Tuesday, [ ] Wednesday, [ ] Thursday, and/or [ ] Friday
q Walks home
q Other (please provide specific details on space provided)