* Required

Please complete and submit the Change Of After School Plan form no later than 12:00 p.m. It is important office and teaching staff have adequate notice to ensure we can support your request. Thank you.

Student Last Name*required

Student First Name*required

Student Grade*

Pre-Kindergarten Kindergarten 1st Grade 2nd Grade 3rd Grade 4th Grade 5th Grade 6th Grade 7th Grade 8th Grade

Pre-Kindergarten Teacher*required

Kindergarten Teacher*required

1st Grade Teacher*required

2nd Grade Teacher*required

3rd Grade Teacher*required

4th Grade Teacher*required

5th Grade Teacher*required

6th Grade Teacher*required

7th/8th Grade Teacher*required

Is this a permanent change?*

No Yes

Which days?*

Monday Tuesday Wednesday Thursday Friday

Today Only?*

Yes No

Dates?*required

Beginning ?*required (mm/dd/yyyy)

My Child will be*required

First and last name of adult that will connect with student.

When “In Person Pick-up Area - connect with an adult other than parent/guardian” is selected, this field becomes available to fill out.

Name of Company

When “Car pick up by a company’s van (daycare, club, etc)” is selected, this field becomes available to fill out.

What time?*required

Only Parents, Legal Guardians and or Emergency Contacts listed in our school records can sign students out of school. Current ID must be presented to office staff. Please note, students will only be retrieved from class once an adult has arrived.

Childcare Name*required

Name of Childcare*required

Childcare Phone Number:*required

Friend's Last Name*required

Friend's First Name*required

Friend's Teacher*required

Person picking up student*required

Bus Number*required

Additional Comments:

Please send a confirmation email to the address below*:

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