Child Pickup Form - Tucson Youth Music Center

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Child Pick-up Authorization Form

Date
MM slash DD slash YYYY
Child's Name
First Last
Parent/Guardian Signature
NO ONE WILL BE PERMITTED TO PICK UP YUR CHILD IF HIS OR HER NAME IS NOT LISTED BELOW. ALL PERSONS MUST HAVE AND SHOW THEIR PICTURE ID WHEN PICKING UP THE CHILD. PLEASE MAKE SURE YOU LIST ALL ADULTS EVEN IF YOU RESIDE IN THE SAME HOUSEHOLD.
THE FOLLOWING ADULTS ARE AUTHORIZED TO PICK UP MY CHILD FROM SCHOOL.
Parent/Guardian*
First Last
Cell Phone
Work Phone
Home Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Parent/Guardian
First Last
Cell Phone
Work Phone
Home Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
PERSON(S) OTHER THAN PARENT/GUARDIAN AUTHORIZED TO PICK UP CHILD
Name
First Last
Cell Phone
Work Phone
Home Phone
Relationship
- Grandparent
- Relative
- Family Friend
- Day Care Provider
Name
First Last
Cell Phone
Home Phone
Work Phone
Relationship
- Grandparent
- Relative
- Family Friend
- Day Care Provider
Name
First Last
Home Phone
Work Phone
Cell Phone
Relationship
- Grandparent
- Relative
- Family Friend
- Day Care Provider
Name
This field is for validation purposes and should be left unchanged.