Sign Out Form

Sign Out Form

Student Sign-Out Form

For the safety of your child, we must have on file a written authorization/permission form from the parent/legal guardian permitting your child to check themselves in and/or out of the program on their own without adult supervision.

Please note that this waiver grants permission for your child to check themselves in and out at Monroe Street Arts Center (MSAC) and leave the program without adult supervision. For your child’s safety, students may sign themselves out from MSAC and leave the facility without adult supervision only when a permission slip is signed, dated by parent/legal guardian, and is on file with MSAC. If MSAC does not have this permission in writing, your child will not be released without adult supervision and will need to be picked up by a parent/guardian or other directly identified adult.

By signing this waiver, I authorize my child to sign themselves in/out of MSAC and enter/leave the facility without adult supervision.

I understand and will make sure my student understands that he/she/they must check out directly with the instructor prior to leaving MSAC. My child will only be allowed to self-check out at the end of the program time unless otherwise arranged by parents with MSAC.

I understand that MSAC is not able to supervise my child after my child leaves the facility and that MSAC cannot be held responsible for my child’s safety in any way after my child signs out and leaves MSAC.

I am signing my child out for: (check all that apply)

2023-2024 Academic Year (Sept. 1, 2023 - May 31, 2024)

Summer 2024 (June 1, 2024 - Aug. 24, 2024)

Child's First Name

Child's Last Name

Child's Date of Birth

Parent/Guardian First Name

Parent/Guardian Last Name

Parent/Guardian Relationship

Parent/Guardian Email Address

Parent/Guardian Phone

Emergency Contact First Name

Emergency Contact Last Name

By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.

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Sign Out Form

Student Sign-Out Form

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