Dorchester
Temporary Change of Dismissal Form
If you are changing your child’s pick up arrangements, you must complete
this form and send it to school with your child on or before the morning of
the dismissal change. Please note that all playdates must be Park and
Pick-up.
Student’s Name:_________________________________________
Student’s Homeroom:____________________________
Is Student regularly a Bus Student?
Yes
No
Date or dates on which change(s) will occur:________________
On the date shown above, this student will:
____ Be dismissed with the Park and Pick Up group and be picked up
by_____________________________________in the cafeteria.
____ Walk/Bike
____ PFA Enrichment (please specify)_____________________
____ Ninth Period (please specify)________________________
____ Other (please specify)______________________________
Parent(s)/Guardian(s) Name:_____________________________
Parent(s)/Guardian(s) Cell Phone #:_______________________
Parent(s)/Guardian(s) Signature:__________________________
Date form submitted to teacher:___________________________