Child Care and Church School

Dismissal Form

The teachers or caregivers of my child ___________________________(Child's Name)

may dismiss him/her into the care of :

Name ________________________________________________

Relationship to child____________________________________

Signature of parent or guardian_____________________________

Date _____________________

Note: It is important that you make sure the teachers/caregivers know the identity of the person you have designated as the alternate for dismissal of your child.