Dismissal Plan and Consent Form
Complete the form for each child attending James A. Jackson Elementary this year.

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Email *
Student's Last Name *
Student's First Name *
Your Best Phone Number *
Name of Emergency Contact #1 *
Emergency Contact #1's Relationship to Student  *
Telephone Number(s) For Emergency Contact #1 *
Name of Emergency Contact #2 *
Emergency Contact #2's Relationship to Student  *
Telephone Number(s)For Emergency Contact #2 *
Does your child have any health concerns? *
Students Grade Level for this year (2022-23) *
On the FIRST DAY of school, I would like my child to be dissmised this way. *
After the first day, my child will typically go home this way. (Choose below)

(I understand that any change to this regular plan must be sent in writing to my child's teacher.  Only in an emergency, can changes be taken by telephone in the school office.) *
Does your child have a sibling (brother /sister)  at the school that they will be going home with each day? *
Car Riders: If you indicated that your child is a car rider, please type the name and relationship (to your child) of the person(s) approved to pick up your child.
Bus Riders: If you indicated that your child is a bus rider and you know the bus number, please type the bus number here.
Day Care: If you indicated that your child will ride a daycare bus, please type in the name of the daycare here.
Please type your full name as signature of Parent/Guardian *
Teacher's Name
Clear selection
If you would like to grant permission for other adults to check your child out of school  or pick your child up after school. (Please provide their name here) *
A copy of your responses will be emailed to the address you provided.
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