Dismissal Change Form

	We accept dismissal changes up until 2:15 PM every day except Wednesdays. 1:15 PM is the deadline on Wednesdays. Dismissal Change Requests will not be read after cutoff times.

1.	Student's Last Name:*

2.	Student's First Name*

3.

Please dismiss my student to (pick one):*

	Car pick up line
	Extended Day
	Bus

Other

4.	What is the first day this dismissal change will be in affect?*

5.	What is the last day this dismissal change will be in affect?*

6.	Additional comments:

7.	Your full name:*

8.	Your relationship to the student:*

9.	Your email address:*