Pirate Dismissal Change Request Form

Submit this form to request a change to your child's regular dismissal plan. Requests must be received before 2:00 PM.

Today's Date Today's Date / MM / DD YYYY
Student Name Student Name First Last
Teacher
Current Dismissal Method

Current Dismissal Method Car Rider Bus Rider Walk Up Pick Up Day Care Van Walker (dismissed without parent/guardian pickup)
Requested Dismissal Method for Today

Requested Dismissal Method for Today Car Rider Bus Rider Walk Up Pick Up Day Care Van Walker (dismissed without parent/guardian pickup)
Daycare:
Please enter the name of the daycare or after-school program picking up your child today.
Grade Level

Grade Level PK K 1st 2nd 3rd 4th 5th 6th 7th 8th
Middle School ONLY
Have you notified your child of this change?

Middle School ONLY Have you notified your child of this change? Yes No
Permanent Dismissal Change
If Yes, your child will use the selected dismissal method on a continuing basis until the school is notified of a new change.

Permanent Dismissal Change If Yes, your child will use the selected dismissal method on a continuing basis until the school is notified of a new change. Yes No
For student safety and verification purposes, please enter your child's Date of Birth (DOB) and Student Number. Requests cannot be processed without this information.

This is the description of your section break.
Parent/Guardian Email Address
Please provide a valid email address. A verification email will be sent to confirm your dismissal change request has been submitted.
Student Date of Birth Student Date of Birth / MM / DD YYYY
Student Number (Located in your myStudent Portal)
Name of Parent/Guardian Submitting Request Name of Parent/Guardian Submitting Request First Last
Parent/Guardian Phone Number Please provide a phone number where you can be reached in the event we need to contact you regarding this dismissal change request. Parent/Guardian Phone Number
Please provide a phone number where you can be reached in the event we need to contact you regarding this dismissal change request. - ### - ### ####
Draw your signature into the box below.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.

Pirate Dismissal Change Request Form

Pirate Dismissal Change Request Form

For student safety and verification purposes, please enter your child's Date of Birth (DOB) and Student Number. Requests cannot be processed without this information.