Date

Teacher & Room #

One Day Change for _________________(date) Permanent Change every ________________(day)

Please excuse _______________________________ to be:
check one:

Picked up from McT at ______time_____by ____________name__________
Dismissed with walkers

THIS FORM MUST BE DELIVERED TO THE TEACHER AT THE BEGINNING OF THE SCHOOL DAY OF THE CHANGE IN DISMISSAL PROCEDURE. OTHERWISE THE STUDENT MAY HAVE TO GO HOME ACCORDING TO THE USUAL PROCEDURE. DISMISSAL CHANGES CANNOT BE TAKEN OVER THE PHONE, EXCEPT IN AN EMERGENCY.

__________________{Parent's Signature}______________

________________{Parent's Daytime Phone} ______________

Date

Teacher & Room #

One Day Change for _________________(date) Permanent Change every ________________(day)

Please excuse _______________________________ to be:
check one:

Picked up from McT at ______time_____by ____________name__________
Dismissed with walkers

THIS FORM MUST BE DELIVERED TO THE TEACHER AT THE BEGINNING OF THE SCHOOL DAY OF THE CHANGE IN DISMISSAL PROCEDURE. OTHERWISE THE STUDENT MAY HAVE TO GO HOME ACCORDING TO THE USUAL PROCEDURE. DISMISSAL CHANGES CANNOT BE TAKEN OVER THE PHONE, EXCEPT IN AN EMERGENCY.

__________________{Parent's Signature}______________

________________{Parent's Daytime Phone} ______________