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LaFayette Central School District

5955 US Route 20 West LaFayette, NY 13084
315-677-9728 (p)/315-677-3372 (f)
www.lafayetteschools.org

Early Dismissal Form

STUDENT INFORMATION

Last Name*

First Name*

Middle name

Date of Birth*

PARENT / GUARDIAN INFORMATION

Parent / Guardian Name

Relationship

Date

EMERGENCY DISMISSAL INFORMATION

Go home as usual (by bus)

Go to the sitter / child care center as usual (by bus)

Ride bus to

I will pick up my child at school

My Child is to do the following in the event of an emergency early dismissal:

Please check only one. The school will follow your choice in order to keep our telephone lines open so that we may contact our bus garage and other emergency agencies.

(name and address),

and the telephone number is

Parent/Guardian Signature (use mouse)

Grade

ID#