Homeroom______________________________________________________________________________________________

2005-2006 PERMISSION TO PICK-UP STUDENTS FROM SCHOOL

Student Name___________________________________________________________________________________

Parent/Guardian__________________________________________________________________________________

Home Phone___________________________________________Bus#(If applicable)_______________________________

Street Address___________________________________________________________________________________

Mailing Address__________________________________________________________________________________

Work_________________________________________________________Work Phone________________________

The following are permitted to pick the above named student up from school:

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

Students may only leave school with a parent/guardian or someone listed above. If someone else needs to pick up the student, we must have written permission by the parent/guardian. Students who ride a bus must have written permission before riding a bus other than the one they normally ride, getting off at a location other than their home, or going home with another student. It must be received in ample time for verification.

Parent Signature_____________________________________________________________________________________