PICK UP AUTHORIZATION FORM

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Personal Information

Child's Name

Authorized Pick Up

Please list the persons authorized to pick up your child, including yourself. Each authorized person must be at least 18 years old. The aforementioned child will not be allowed to leave the program without anyone not listed below. Authorized persons may receive the child in person and may be required to show identification to the program staff. Children will not be handed over to persons who do not present an acceptable ID upon request. Please note that children must be picked up at designated times. I authorize the following individuals to remove my child from the program:

I authorize the following individuals to remove my child from the program:

Authorized Person

Phone Number

Relationship to Child

Authorized Dismissal

Clear Signature