Dismissal Authorization Form

Family Information

Family Name*
Preferred Family Name
(The Preferred Family Name will be shown on the dismissal card. Fill in only if different from the Family Name above.)
Preferred Email Address*
Father's Name*
Mother's Name*

Please list all of your children attending Hebrew Academy from CPE to Grade 6.

How many children would you like to add (max. 6)?*

Child #1*

First Name Last Name

Grade*

Will this child be picked up at 4:45pm on regular dismissal days?*

Yes
No

Child #2*

First Name Last Name

Grade*

Will this child be picked up at 4:45pm on regular dismissal days?*

Yes
No

Child #3*

First Name Last Name

Grade*

Will this child be picked up at 4:45pm on regular dismissal days?*

Yes
No

Child #4*

First Name Last Name

Grade*

Will this child be picked up at 4:45pm on regular dismissal days?*

Yes
No

Child #5*

First Name Last Name

Grade*

Will this child be picked up at 4:45pm on regular dismissal days?*

Yes
No

Child #6*

First Name Last Name

Grade*

Will this child be picked up at 4:45pm on regular dismissal days?*

Yes
No

Method of Dismissal*

Note: Unsupervised Walker does not apply to CPE & Kindergarten

Driver #1*

First Name Last Name

Cell Phone #*

Driver #2

First Name Last Name

Cell Phone #

Driver #3

First Name Last Name

Cell Phone #

Supervisor #1*

First Name Last Name

Cell Phone #*

Supervisor #2

First Name Last Name

Cell Phone #

Supervisor #3

First Name Last Name

Cell Phone #

Unsupervised Walker Authorization*

This authorization indicates that you give permission for your child(ren) to leave school on their own at the end of the school day.

I permit my child(ren) listed above to leave the school building after school unaccompanied

Comments (optional)

Authorization & Agreement*

I confirm that I authorize the above named students to participate in the Hebrew Academy Dismissal Program and I agree to abide by the rules and regulations of the program. I certify that the information contained herein is complete and accurate and I will immediately notify the School, in writing, of any changes to this form. I agree and authorize the School to dismiss the above named children to the individuals listed above as applicable. I hereby release and indemnify the School from any liability related to the participation in the Dismissal Program.

I have read the above Authorization and Agreement paragraph and I agree to all of the terms contained therein.

Full Name (Signature)*

Date*

ES Dismissal Authorization