Instructions to parents and guardians:

Please fill out and have your child submit to his/her teacher

EACH TIME daily dismissal is not to follow the usual pattern.

TO: The Office Staff of Stony Creek Elementary School

FROM: _________________________ ____________________________

Parent/Guardian Name –please print Parent/Guardian Signature

RE: _________________________ ____________________________

Child’s Name - please print Grade & Class

He / She usually:

q takes Bus #________ home

q walks home

q goes to the “Y” Program

________________________________ who is the child’s _______________________

Name of person picking up child Relation to child

will pick him / her up from the sign-out line on _____________________ at _______ or

Day & Date Time

every q Mon. q Tues. q Wed. q Thurs. q Fri.

until otherwise notified. He / She agrees to use a picture I.D. to identify Himself / Herself.

If you have any questions please call the office at: 215-619-8108

PLEASE NOTE: If the above dismissal change is altered, you must notify us by filling out another form.