Austin Elementary School Austin Elementary School
CHANGE OF DISMISSAL FORM CHANGE OF DISMISSAL FORM
Date(s) of Change:______________________________ Date(s) of Change:______________________________
Student Name:_________________________________ Student Name:_________________________________
Grade:___________ Teacher:_____________________ Grade:___________ Teacher:_____________________
HOW WILL YOUR CHILD BE DISMISSED? HOW WILL YOUR CHILD BE DISMISSED?
□ School Bus □ School Bus
Bus #__________________________________ Bus #___________ _______________________
□ Carpool □ Carpool
Carpool #________with_______________________ Carpool #________with_______________________
□ Early Check-Out (BEFORE 2:00P.M.) □ Early Check-Out (BEFORE 2:00P.M.)
Time:_________________________ Time:_________________________
□ Other:_________________________________ □ Other:______________________________________
Parent Signature:_________________________ Parent Signature:______________________________
Phone Number:___________________________ Phone Number:________________________________
