Mentor Christian School

Early Check-out Form

Student’s Name    Grade 1 2 3 4 5 6 7 8 9 10 11 12     Date

Reason for leaving early:                     Illness

                                                                Doctor or Dental Appointment

                                                                Emergency at Home

                                                                Other

Explanation of “Other” or “Emergency at Home”

                    Proposed Time of Departure

Parent Signature:  _________________________

-------------------------------(For Office Use) --------------------------------------------

Initials of teachers whose classes will be missed:    ______      ______      ______      ______

                                                                                           ______      ______      ______      ______

Approved                _______________

Disapproved           _______________

Note:  Once approved, the school secretary may check students out or back into the school.

                                                                                                                Time of Departure                   _____________________

                                                                                                                Time of Return                        _____________________

                                Signature of person picking up the student:   ____________________________