2023-2024 Student Self-Dismissal Consent

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Please read and fill out this form ONLY if your middle school child has permission self-dismiss.

If your child will not be picked up by a parent or other designated person at the end of the school day, complete below, giving your consent to have your child leave the school on his/her own to use public transportation, take a cab, walk to your home/office, etc.

Daystar Academy, its respective directors, officers, and employees are not liable for any actions taken by the student after having left the school (including traveling to a location against parents' will and/or tardiness in going home.)

Student Name *

Student's grade *

6th

7th

8th

I hereby grant permission for my child to leave the Daystar Academy premises at DISMISSAL (2:45pm) on their own without parental supervision. *

Yes

No (if not, you do NOT need to complete this form!)

He/She may leave school at dismissal in this manner (must choose one): *

Daily WITHOUT a phone call or note from me to the school. (Please update PikMyKid to reflect this.)

Only when I update PikMyKid to communicate to school staff that my child will leave school without parental supervision. Note: PikMyKid must be updated by 1:00pm. Calls/Emails received within 1 hour of dismissal cannot be communicated and the child will wait until a parent is able to pick them up.

Only on certain days (give details below and update PikMyKid with this schedule!)

N/A: I do NOT give permission for my child to self-dismiss. (You do not need to complete this form!)

Details about end of school dismissal...(which days, what time, any other info that would help us!)

I hereby grant permission for my child to leave the Daystar Academy premises after a sports practice on their own without parental supervision. Please give details below. *

Yes, after every practice

Yes--but only when I email Mr. Ploegstra and/or my child's coach with this information

No, I do not give permission for my child to self-dismiss from sports.

(not applicable to my student)

Details about sports dismissal...(which sport, who can they leave with, etc.)

The undersigned hereby releases Daystar Academy, its respective directors, officers, and employees of and from any and all claims whatsoever arising or which may arise by reason of the child leaving Daystar Academy as outlined above and without direct adult supervision including such claims due to personal injuries or illness. I have read this waiver and agree to the terms thereby. My child has permissions as I have outlined in detail above. *

Yes

Parent e-signature *

Today's Date *

YYYY

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