Early Dismissal Request

Student’s Name __________________________________________________

                                                  Last                                        First

Year of Graduation ____________  Section ___________________________

Date for Dismissal _____________ Time of Dismissal ____________AM/PM

Reason for Early Dismissal ________________________________________

______________________________________________________________ 

______________________________________________________________ 

Student will return to school:        ÿ Yes       ÿ No

Parent/Guardian Signature ______________________________________ 

Home Phone Number ____________  _______________________

                         (Area Code)        (Phone Number)

Cell Phone Number ____________  _______________________

                         (Area Code)        (Phone Number)