Date:

____________________________

Child's Name:

____________________________

Teacher' s Name:

Parent/Guardian/Designated Adult Pick Up

My child will not take the bus home today, but will be picked up by:

____________________________________________

Early Dismissal

Please dismiss my child today at _________________ for ____________________________.

He/she will be picked up by:  ____________________________

Alternate Dismissal Arrangements (to be used only on dates when your child will not follow his/her usual dismissal procedure).

At dismissal today, my child (please check item that applies) ...

__

__

__

__

__

__

__

Will not go to ECEC ... send home on bus.

Will go to ECEC

Will/will not attend CCD

Will stay after school with __________________________

Will not stay after school with _______________________

Will go home on bus __ with ________________________

(Permitted only for child care purposes)

Parent's/Guardian's Signature:  _______________________________