* Required

Plymouth Elementary School Dismissal Change Form

Student First Name*required

Student Last Name*required

Grade Level*

Kindergarten 1 2 3

Teacher Name/Room Number

Mrs. DeLaRosa/Room 123 Mrs. Furness/Room 101 Mrs. Handis/Room 121 Mrs. Remaily/Room 102 Mrs. Rodenbaugh (Keller)/Room 119 Mrs. Webster/Room 103 Mrs. Williams/Room 120 Mrs. Youells/Room 104

Teacher Name/Room Number

Mrs. Chubb/Room 206 Mrs. DiRenzo/Room 220 Mrs. Erwin/Room 204 Mrs. Kim/Room 221 Mrs. Pileggi/Room 201 Ms. Sagel/Room 203 Mrs. Weidamoyer/Room 207 Mrs. Wilson/Room 202

Teacher Name/Room Number

Mrs. Badmann/Room 214 Mrs. Barone/Room 216 Mrs. Diedel/Room 213 Mrs. Grimshaw/Room 209 Mrs. Hartel/Room 208 Mrs. Kelley/Room 210 Mrs. Klein/Room 211 Mrs. Kucher/Room 215

Teacher Name/Room Number

Mrs. Bolasky/Room 108 Mrs. Hendrickson/Room 113 Mrs. Lobos/Room 110 Mrs. Morris/Room 106 Mr. Pezzano/Room 114 Ms. Porter (Smith)/Room 109

Dates of Change*required

Student Will Be Changing To:*

Choose one.

Walker Carline pick up by parent/guardian Carline pick-up by other adult Taking assigned bus home Attending Wonderspring Taking van to childcare, religious school, etc. Other

Please be specific.*required

Name of Adult Picking up Student*required

First and last name. Must be listed in PowerSchool and bring identification.

Student's Bus Number*required

Parent/Guardian Name*required

Parent/Guardian Email *required

NOTE: The parent/guardian email address listed below may be checked against school records.

Today's Date*required (mm/dd/yyyy)

Please send a confirmation email to the address below*: