School Walkers Permission Form

Purpose of Form

This form grants permission for the listed students to walk home from school at dismissal. The school requires parent/guardian consent for any student who will be walking home regularly, either alone or with a sibling/friend.

Name

First NameLast Name

Grade

Walks alone or with someone

With sibling/friend

Days Allowed to Walk (e.g., M-F)

Name

First NameLast Name

Grade

Walks alone or with someone

With sibling/friend

Days Allowed to Walk (e.g., M-F)

Name

First NameLast Name

Grade

Walks alone or with someone

With sibling/friend

Name

First NameLast Name

Grade

Walks alone or with someone

With sibling/friend

Days Allowed to Walk (e.g., M-F)

Name

First NameLast Name

Grade

Walks alone or with someone

With sibling/friend

Days Allowed to Walk (e.g., M-F)

Name

First NameLast Name

Grade

Walks alone or with someone

With sibling/friend

Days Allowed to Walk (e.g., M-F)

Method of Transportation (Check All That Apply)

Rides with a friend (By Whom?)

Picked up (By Whom?):

VA = Daycare-provided transportation or van service. Please make sure the school has contact info for any third-party service providers.

Additional Details (if applicable):

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number at Location (if available)

Please enter a valid phone number.Format: (000) 000-0000.

Student's Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Parent/Guardian Authorization

I give permission for the students listed above to walk home from Victory Christian Academy school on the days indicated. I understand that once dismissed, the school is no longer responsible for their supervision. I agree that my child(ren) understands safety procedures, including crossing streets and walking home responsibly.

Parent Name

First NameLast Name

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Signature

Date

School Walkers Permission Form

List of Student Walkers

Walk-To Address