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Authorization Pick Up List

Authorized Pick-Up List

The people listed below have my authorization to pick up my child from the program.  I will inform my child’s director/teacher, each time a special pick-up is necessary.  I understand that my child will only be released to individuals listed below, if I become unavailable and that the school may also relay a message regarding my child’s day if necessary.  I also realize that they will be required to provide proper identification each time that they arrive at the center for identification purposes.  If an individual is not listed on the form, a phone call WILL NOT be sufficient to release the child to that individual. 

Mother’s/Guardian’s Signature ___________________________________ Date ____________

Father’s/Guardian’s Signature ____________________________________ Date_____________

Child’s Name ___________________________

Please Print:

 

            Name               Relation to Child                     Address                       Phone (Home/Cell)    

______________________________________________________________________________

            Name              Relation to Child                     Address                       Phone (Home/Cell)

______________________________________________________________________________

            Name               Relation to Child                     Address                       Phone (Home/Cell)

______________________________________________________________________________

            Name              Relation to Child                     Address                       Phone (Home/Cell)

______________________________________________________________________________

            Name              Relation to Child                     Address                       Phone (Home/Cell)

These people are NOT allowed to pick up my child.

PLEASE NOTE: A copy of the court decision for custody cases MUST be on file in order for the program NOT to release a child to his/her non-custodial parent.

______________________________________________________________________________

            Name               Relation to Child                     Address

______________________________________________________________________________

            Name              Relation to Child                     Address