Exploration Experience Late Pick Up Form
For students picked up from ASES Funded Programs.
THIS FORM TO BE COMPLETED BY
STAFF
ONLY
Site Name
*
Please Select
Bryn Mawr
Clement
Cope
Franklin
Kingsbury
Lugonia
McKinley
Mentone
Moore
Victoria
Name of Staff Completing Form
*
First Name
Last Name
SITE LEAD EMAIL
*
@YMCAEASTVALLEY.org
Student's Name
*
First Name
Last Name
Additional Students
Name of Person Picking Up
*
First Name
Last Name
Relationship to Student
*
Please Select
Parent/Guardian
Relative
Family Friend/Neighbor
Other
Email (optional)
example@example.com
Phone Number (optional)
Please enter a valid phone number.
Format: (000) 000-0000.
Late Pick Up Date & Time
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Reason Given, if any (STAFF ONLY COMPLETE)
*
Parent/Guardian Acknowledgment (not to be completed by other relations)
I acknowledge that I was late to pick up the student(s) from the Exploration Experience Program. Elementary sites close at 6:00PM. Middle School sites close at 6:15PM.
I understand that there may be consequences for late pick-ups including fees of $10 + $1 per minute after the closing time, and possible dismissal from the program.
Signature of Person Picking Up
If parent did not sign, did they refuse to sign?
Yes
No
Please include any notes administration should be aware of.
Submit
Should be Empty: