Merriam Dismissal Form

Revised Dec. 16, 2003.

Teacher: _____________________________ Room: ______ Date: ____/____/____

Please excuse __________________________________ who will be:
  (Student name)
 
Picked up from Merriam at: ______________, by ____________________________.
  (Time) (Name)
Returned to Merriam at: _________________.
  (Time)

Dismissed with walkers.

Other: ________________________________________________________
 
  ________________________________________________________

_________________________________________________
(Parent/guardian signature)

_________________________________________________
(Parent/Guardian daytime phone number)