Dismissal Change Request

If you wish to change your child(ren)'s dismissal, please fill this out no later than 3pm.

Parent Name
Child's Name
Child's Grade & Teacher (If your child is in 3rd-5th grade, please list the AFTERNOON TEACHER.)
Second Child's Name (if applicable)
Second Child's Grade & Teacher (If your child is in 3rd-5th grade, please list the AFTERNOON TEACHER.)
Third Child's Name (if applicable)
Third Child's Grade & Teacher (If your child is in 3rd-5th grade, please list the AFTERNOON TEACHER.)
My child(ren)'s typical dismissal is:
Today, my child(ren) will be:
Additional Information
I understand that I cannot add a pickup person to this form that is not already on my child's card. This must be done in person. Please initial.