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Change in Dismissal Form

WSD Change in Dismissal Note

Last Name: _____________________First Name: ____________________

Grade: ____Teacher/Homeroom: ____________________


Date: ________________________________Time: __________

Elementary Only:

☐ Student will be a parent pickup today by _________________________________

☐ Student will take the bus home today.

☐ Other Plan: ______________________________________________________________________

REASON FOR ABOVE: _____________________________________________________________________

Parent/Guardian Signature: ___________________________________