*
Required
Student Last Name
*
required
Student First Name
*
required
Student Grade*
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
ALC
Kindergarten Teacher
Please Select…
DONNELLY, Ruann
REYNAUD, Gladys
SELBY, Polly
1st Grade Teacher
Please Select…
BROCK, Rachel
CAPLAN, Ann Marie
GUERRA, Krisi
2nd Grade Teacher
Please Select…
PERRIGAN, BrieAnne
RENNIE, Brie
RIOS, Keeley
3rd Grade Teacher
Please Select…
EVANS, Wendy
PORTER, Ben
YAMADA, Kirsten
4th Grade Teacher
Please Select…
GELLING, Michael
NICE, Maggie
WILLIS, Margaret
5th Grade Teacher
Please Select…
CLARKSON, Jim
LESTER, Rylan
COOK, Laura
ALC Teacher
Please Select…
EDENS, Leann
THERRIEN, Lori
Is this a permanent change?*
No
Yes
Which days?*
Monday
Tuesday
Wednesday
Thursday
Friday
Today Only?*
Yes
No
Dates?
*
required
Beginning ?
*
required
(mm/dd/yyyy)
My Child will be
*
required
Please Select…
picked up early.
car pick up.
car pick up by an adult other than the parent/guardian.
going home with a friend in the car pick up
going home by bus.
going home with a friend by bus.
going to daycare.
walking
walking home with another student
What time?
*
required
Parents/guardians and or/emergency contacts MUST sign student out in the front office.
Will they return to school today?*
Yes
No
Childcare Name
Please Select…
Bethany Childcare
Crafty Mindz
Kindercare
Art World
Club K
Other
Name of Childcare
Childcare Phone Number:
Friend's Last Name
Friend's First Name
Friend's Teacher
person picking up student
Bus Number
Additional Comments
Please send a confirmation email to the address below*: