CHS EARLY DISMISSAL FORM

This form must be turned in to the Front Office BEFORE school starts.

_____________________________________, _______, ________________

(

print student name AND student number) (grade) (student birthday)

will need to be released early from school on _________________ at __________

and

(date) (time)

will be checked out by ________________________________________.

____________________________________

(parent/guardian name – please print)

___________________________________________

(parent/guardian signature)

____________________________________________________

(parent contact info.-phone number)

OR Student Driver:

Student will be driving him/herself to said destination. I understand the policy requires someone from the

Attendance Office to call me and

reconfirm that my child has permission to leave the school campus.

_____________________________________

(parent/guardian name – please print)

___________________________________________

(parent/guardian signature)

____________________________________________________

(parent contact info - phone number)

I understand my child may only be checked out by the adult or sibling listed. I am also aware

the procedure is to go to the Attendance Office to sign the student out and a photo ID is

required. Students may not check out fellow students.

Check one:

(please print)

Illness (self, immediate family)

Doctor/Dentist appointment

Academic event

Court appearance

Religious holiday

Death of family member

Important: It counts as a day when a student misses 3 or more periods. After fifteen (15) days of

absence, whether excused or unexcused, a student will be required to turn in a doctor's note for

every subsequent absence, tardy and early dismissal to be considered excused.