Extended Ed. Office: (707) 664-2394

EXCEL Special Release/SSU

(Please print, fill out, and return to teacher)

ATTENTION PARENTS:

If you work on campus, have unusual pick-up requests, or your child takes the bus, walks home or rides a bicycle (bring a good lock), signing this form releases SSU of any responsibility for your child.

Child's Name_____________________________________________________________

Parent's Name_____________________________________________________________

Day Time Phone Number_________________________________

AM class____________________________________PM class___________________________________

Signature_________________________________________________________Date_________________

Statement of how and where the child is to be released (please write below):