Check Out Form

Date & Time Leaving: __________________________________________

Date & Time Returning: ________________________________________

Student's Name: ______________________________________________

Destination: _________________________________________________

Reason for checking out student: ____________________________________________________________

______________________________________________________________________________________

Person checking out student (Print name clearly): _______________________________________________

Relationship to student: ___________________________________________________________________

Phone number: _________________________________ License Plate No.: _________________________

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Students should not be checked out past 9:00 pm on school nights and 12:00 am Fridays and Saturdays.

A staff member needs to be on duty one full year and obtained proper permission to check students out of the dormitory for any reason.

Any student that has accumulated 3 days per semester of unexcused absences may not be promoted.

If a student is on restriction upon check out, another major will be written.

A student cannot drive any vehicle unless accompanied by the party who checked the student out of the dormitory.

The school reserves the right to forbid anyone from checking out a student at any time.

Student must be accompanied by person checking them out at all times.

I have read the above terms and understand that I am responsible for the student and conditions of this checkout. If these conditions are not followed, future checkouts will be denied.

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Signature of Legal Guardian/Parent or Authorized Designee Checking out Student	Date