Student Last Name*

Student First Name*

Kindergarten Teacher*

1st Grade Teacher*

2nd Grade Teacher*

3rd Grade Teacher*

4th Grade Teacher*

5th Grade Teacher*

EGC Teacher*

Is this a permanent change?*

No Yes

Today Only?*

Yes No

Dates?*

Beginning ?* (mm/dd/yyyy)

My Child will be*

What time?*

Parents/guardians and or/emergency contacts MUST sign student out in the front office. Students will only be called from the classroom once an adult arrives to pick them up.

Childcare Name*

Name of Childcare*

Childcare Phone Number:*

Friend's Last Name*

Friend's First Name*

Friend's Teacher*

person picking up student*

Bus Number*

Please send a confirmation email to the address below*: