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:___________________