Early Dismissal Request Form

This form is required and is not be to submitted more than 24 hours before the date of the requested early dismissal. Parent/Guardian(s) who do not submit this form will be required to wait while the paper is processed and the student is located. Proper identification will be required upon pick-up to confirm parent/guardian identity.

Only parent(s), guardian(s), and Emergency contacts on the School Account can pick up a student

Student drivers are permitted to leave early with signed permission form and a telephone confirmation from the parent/guardian on PowerSchool. Parent/Guardian(s) who wish for their child to drive themselves must indicate so on this form.

Inaccurate information may result a wait for an undisclosed amount of time.

Student Name*

First NameLast Name

Student Grade*

9101112

Student Number (6 Digit PowerSchool Number)

Early Dismissal Date*

Date

Early Dismissal Time*

Hour Minutes

AM/PM Option

Will your child be returning to school following the appointment?*

YesNo

Who is Picking up your Child?*

My child drives to school and will drive to the appointment (school will call to confirm)I will come to school and sign my child out of schoolA contact on PowerSchool will sign my child out of schoolOther (if other, please provide full legal name, relationship, and phone number)

My child understands he/she must come to the Main Office prior to leaving and sign out with the office.*

Yes

Parent/Guardian's Name*

First NameLast Name

Best Contact Number for Parent/Guardian*

Please enter a valid phone number.

Parent Email*

example@example.com

Reason for Early Dismissal*

Proof of Doctor's Appointment

Parent/Guardian Signature*