ParentStudentHandbook2017-18 AUG.17

Escort Dismissal Request for Supervision at Dismissal Form

Child’s Name:

Homeroom Teacher:

Grade:

Parent/Legal Guardian Home Phone:

Work Phone:

Cell Phone:

I am requesting the school only release my child to his/her parent/legal guardian or the escorts I have designated below. By signing at the bottom of this form, I understand the following:

● All students using Escort Dismissal must be picked up in the school car line.

● Students designated as participating in escort dismissal will be supervised with the car line students until the regular car line has been completed.

● This dismissal procedure shall be effective upon school official signature and shall apply to all school days including early dismissal days.

● Once my child leaves the school property with their designated escort, the district is not responsible for my child’s actions or the actions of the designated parent/guardian or escort.

● In the event that my child is not picked up on time or by the designated adults, my child will be placed in the after school PAL’s program and I will be responsible for the costs associated with PAL’s.

● Any designated escort must by 18 years or older.

● Any parent/guardian or escort should be prepared to show ID to school personnel and must sign the dismissal log. ● My child will not be dismissed to any person not listed on this form. ● This agreement will remain in effect for the entire school year unless revoked in writing. The following are designated to pick up my child after school from the car line: Parent/Legal Guardians Designated Escorts: 1. 1. 2.

2. 3. 4.

Parent/Guardian Signature:

Date:

School Office Approval:

Date:

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