NW Islamic School
Late Pick-Up Notice Form
NW Islamic School is committed to the safety and supervision of all students. Students must be picked up promptly at the end of the school day. This form is issued when a student is not picked up within the designated time. Repeated late pick-ups may result in additional fees or further action in accordance with school policy.
Section 1: Student Information
Student's Full Name:
Grade/Class:
Date of Incident:
-
Month
-
Day
Year
Date
Section 2: Late Pick-Up Details
Scheduled Pick-Up Time:
Hour Minutes
AM
PM
AM/PM Option
Actual Pick-Up Time:
Hour Minutes
AM
PM
AM/PM Option
Duration Late: minutes
Person Who Picked Up the Student:
Relationship to Student:
Section 3: Reason for Late Pick-Up
Traffic or transportation delay
Work-related delay
Emergency (please describe below)
Miscommunication about pick-up time
Other (please specify):
Additional explanation (if applicable):
Back
Next
Section 4: Late Pick-Up Policy Reminder
Students must be picked up within
15 minutes
of the scheduled dismissal time.
After 15 minutes, staff will attempt to contact the parent/guardian and emergency contacts.
A Late Pick-Up Notice will be issued for each occurrence.
Repeated late pick-ups (3 or more per term) may result in a late pick-up fee of $_________ per occurrence.
Chronic late pick-ups may require a parent meeting with administration.
Section 5: Occurrence Record
This is occurrence number for the current academic year.
Previous late pick-up dates (if any):
Section 6: Parent/Guardian Acknowledgment
I acknowledge receipt of this Late Pick-Up Notice. I understand the school's late pick-up policy and will make every effort to ensure my child is picked up on time.
Parent/Guardian Signature:
Date:
-
Month
-
Day
Year
Date
Office Use Only
Issued By (Staff Name):
Date Issued:
-
Month
-
Day
Year
Date
Copy Provided to Parent:
Yes
No
Notes:
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