Request For Supervision At Dismissal From School Form/west New York Public Schools printable pdf download

West New York P

UBLIC

CHOOLS

Request for Supervision at Dismissal from School Form

Any parent(s) or legal guardian(s) of a pupil attending a district-operated school or program in grades Pre-Kindergarten

to twelve, where the pupil is not eligible for District-provided transportation or is eligible and elects not to use district-

provided transportation after dismissal may request the school or program to release the pupil to walk home after

dismissal without the need to be released to the parent(s) or legal guardian(s). The parent(s) or legal guardian(s) may

also permit students to be released to an escort other than the parent or legal guardian. The parent or legal guardian

may designate up to three escorts. The parent(s) or legal guardian(s) requesting their child(ren) be released to an escort

will only be released to a parent(s) or legal guardian(s) or parent(s) or legal guardian(s)-designated escort after dismissal

must submit a completed Request for Supervision at Dismissal from School Form to the Principal or designee, or

program administrator. Additionally, pupils will only be released unescorted upon receipt by the District of the Request

for Supervision at Dismissal from School Form.

The Form shall be made available in the Main office of the school building or the location of the program; upon request to

the Principal, or designee, or the program administrator; on the school or school district website; and to parent(s) or legal

guardian(s) in the beginning of the school year.

In order for the school administration to effectively implement the requirements of this Policy and to ensure the safety

and security of pupils that will be released, the parental request shall be applicable for every school day and shall apply

for a duration period of the entire school year. The Request Form must be resubmitted at the end of the duration period.

In addition, a parent(s) or legal guardian(s) may rescind their Request by submitting a written request to the Principal or

program administrator indicating the date in which the parent(s) or legal guardian(s) no longer requests the school

provide supervision of their child(ren) after school dismissal. The child(ren) will be dismissed in accordance with typical

dismissal protocol effective the date indicated in the rescinding request.

___I hereby give permission for my son/daughter to walk home unescorted from school.

___I do NOT give permission for my son/daughter to walk home unescorted from school.

___My child should only be released to the following designated escort(s):

1. _____________________

Relationship ______________

2. _____________________

Relationship ______________

3. _____________________

Relationship ______________

Student Name ______________________________________________________

School: ___________________________________________________________

Grade/Homeroom Teacher Name: ______________________________________

Parent/Guardian Name (PRINT):________________________________________

Parent/Guardian Signature: ___________________________ Date: ___________

School Year ______ - _______

(P lease fill out one of these form s for each child.)

Request For Supervision At Dismissal From School Form/west New York Public Schools