Clinton Off-Campus Lunch/Recess

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Please fill out this form daily by 10:00 AM if you will be picking up your child for Off-Campus Lunch. Students must be picked up at the start of their recess/lunch block and returned when the block ends. The parent/guardian must sign the student out at Door 1 (Main Entrance). Please bring identification. The parent/guardian must also sign the student back in at the end of the Recess/Lunch Block. If procedures are not followed by parents, then the privilege of "Off Campus Lunch" may be revoked by Administration.

Email *

Student Name (Only One Student) *

Teacher Name *

Student Grade Level (Choose one) *

Kindergarten 11:45 - 12:40

First Grade 12:10 - 1:05

Second Grade 12:35 - 1:30

Third Grade 10:55 - 11:50

Fourth Grade 10:30 - 11:25

Fifth Grade 11:20 - 12:15

Student Name (Only One Student)

Teacher Name *

Student Grade Level (Choose one)

Kindergarten 11:45 - 12:40

First Grade 12:10 - 1:05

Second Grade 12:35 - 1:30

Third Grade 10:55 - 11:50

Fourth Grade 10:30 - 11:25

Fifth Grade 11:20 - 12:15

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I understand that students must be picked up and returned at the start end of Recess/Lunch Block for their grade level. Failure to do so may result in the loss of this privilege. *

Yes, I agree

A copy of your responses will be emailed to the address you provided.

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