Cedar Middle School
Student Check Out Form
Student Name: __________________________________ Grade: _________________
Parent/Guardian: ________________________________ Phone: _________________
According to Iron County School District and Cedar Middle School policy, students will not be allowed to be checked out of school by any person other than their parent/guardian or emergency contacts listed in PowerSchool unless a parent/guardian gives permission for the student to be checked out. This form will serve as permission for student check out for those adults not listed on the student’s emergency contact and must be completed and on file at Cedar Middle School each school year. This form will expire at the end of the school year and a new form must be filled out each year with updated information.
Please note – The office cannot call students out of class early to go to lunch as this causes a disruption to the entire class and the learning process. If your student is being checked out for lunch please make sure that they return on time so as not to disrupt the class and other student’s learning.
Person Authorized to Check-Out Student:_________________________________________________________
Phone:__________________________ Relationship to Student: ___________________________________ Reason for Checkout: _________________________________________________________________________
Dates of Checkout Authorized: __________________________________________________________________
Person Authorized to Check-Out Student:_________________________________________________________
Phone:__________________________ Relationship to Student: ___________________________________ Reason for Checkout: _________________________________________________________________________
Dates of Checkout Authorized: __________________________________________________________________
Check-Out
Authorization: __________________________ Phone:_________________ Relationship:_____________
Person Authorized to Check-Out Student:_________________________________________________________
Phone:__________________________ Relationship to Student: ___________________________________ Reason for Checkout: _________________________________________________________________________
Dates of Checkout Authorized: __________________________________________________________________
Person Authorized to Check-Out Student:_________________________________________________________
Phone:__________________________ Relationship to Student: ___________________________________ Reason for Checkout: _________________________________________________________________________
Dates of Checkout Authorized: __________________________________________________________________
Parent/Guardian Signature: ________________________________________ Date:___________________