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78  2:00-3:25JH-------11:45-12:10

    Seymour Community School

              Park & Main

       Seymour, Iowa  52590

Student Checkout Form   [*See Activity Expectations]Year ____

Date ______________

Student Name ___________________

Students: make sure you have your teacher for each period sign you out.

Class/SH [ periods]      Teacher SignatureAmount Owed

1st ____________________________________

2nd ____________________________________

3rd ____________________________________

4th ____________________________________

5th ____________________________________

6th ____________________________________

7th ____________________________________

8th ____________________________________

P.E. Lock ______#___________

Other Debts [coaches—add any items in below] ----  

Coaches __________  ____________  _________ Total _______

Locker cleaned out –verified by staff  _________

Library Fine----------------------------------   ___________

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