Whitemarsh Elementary School Dismissal Change Form

Student First Namerequired

Student Last Namerequired

Grade Levelrequired

Kindergarten

1

2

3

Teacher/Room Number

Brennan/Room 3

D'Eletto/Room 5

Student Will Be Changing To:requiredChoose one.

Walker

Carline pick up by parent/guardian

Carline pick-up by other adult

Taking assigned bus home

Attending Wonderspring

Taking van to childcare, religious school, etc.

Other

Choose one.

Please be specific.required

Name of Adult Picking up Studentrequired

First and last name. Must be listed in PowerSchool and bring identification.

How long is the change?required

One Day

Multiple Days

What day is the dismissal change?required

Must contain a date in M/D/YYYY format

What day does the dismissal change start?required

Must contain a date in M/D/YYYY format

What day does the dismissal change end?required

Must contain a date in M/D/YYYY format

Is there anything else we need to know about the change?

Example: Tuesday and Thursday only.

Student's Bus Numberrequired

Parent/Guardian Namerequired

Parent/Guardian Email required

NOTE: The parent/guardian email address may be checked against school records.

Today's Daterequired

Must contain a date in M/D/YYYY format

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