Date Submitted:     School Year Requested:

Name of Student (last, first, middle):

I am applying for early dismissal from school for because:

I have transportation away from school each and and will not, on any day, be on the campus

longer than five (5) minutes after being dismissed.  Students who are granted an early dismissal

must leave campus as stipulated.  If the a student is to be on campus for any reason beyond their

dismissal time he/she must consult their grade-level principal granting the early dismissal and be

under the direct supervision of a faculty member. Failure to adhere to the rules of early dismissal

will result in a student being reassigned.

Parent's Signature:______________________________________________________

Student's Signature:_____________________________________________________

Home Phone:___________________ Work Phone:____________________________

                    Approved: ________

                Disapproved:________

Counselor or Principal's Signature:___________________________________________