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Child Pick-up Authorization Form
PARENTS AND GUARDIANS: Please complete this form for each child you are registering.
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
Section End
Name
This field is for validation purposes and should be left unchanged.
