Early Dismissal Form

Date of Early Dismissal

Student's First Name

Student's Last Name

Grade - Select -Select GradePreschoolKindergartenFirst GradeSecond GradeThird GradeFourth GradeFifth GradeSixth Grade

Classroom Teacher

Dismissal Time

Student will return to school

Yes

No

At approximately what time will the student return to school?

Parent/Guardian First and Last Name

Parent/Guardian Phone Number

Parent/Guardian Email

Parent/Guardian Signature

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Leave this field blank