Self-Dismissal Authorization Form

Self-Dismissal Authorization Form

Authorize your child to leave at the end of their scheduled program time and provide guardian contact details.
Student Name

First NameLast Name
Parent/Legal Guardian Name

First NameLast Name
Parent/Legal Guardian Email
example@example.com
Parent/Legal Guardian Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Program/Location
By signing this form, I authorize my child to self-dismiss from the New York Chess Academy at the end of their scheduled class. I understand that once my child is dismissed from the classroom/program area, New York Chess Academy and its instructors are no longer responsible for my child’s supervision or whereabouts. I am aware of the program's scheduled end time and have made appropriate arrangements with my child regarding their transportation and post-class destination.
Parent/Legal Guardian Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: