DBES Change of Dismissal Form
DBES Change of Dismissal Form
Changes must be submitted by 3:15 pm for same day dismissal changes.
Student Name
Student Name
*
First
Last
Grade Level
*
Grade Level
Pre-K
Kindergarten
1st grade
2nd grade
3rd grade
4th grade
5th grade
Date of Change
Date of Change
*
/
MM
/
DD
YYYY
Permanent Change?
*
Permanent Change?
Yes
No
Current Dismissal Method
*
Current Dismissal Method
Walker/biker
Car rider
School bus
Daycare van
PLACE
Change of Dismissal Requested
*
Change of Dismissal Requested
Walker/biker
Car rider
School bus (MUST already have a bus pass to choose this option)
Daycare van (daycare must have prior knowledge of the change)
PLACE (must be a registered student)
Daycare Van Name (if applicable)
Name of person requesting the change:
*
Email
*
Contact Number for questions
Contact Number for questions
*
-
###
-
###
####
I am aware that changes of dismissal are not permitted after 3:15 pm on the same day as the change.
*
I am aware that changes of dismissal are not permitted after 3:15 pm on the same day as the change.
I am aware that changes after 3:15 pm on the same day will not be honored.
Spam Protection. Please answer this simple question:
4, 5, 6, 7 : the 3rd number is?