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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 am unavailable.  I also realize that they will be required to provide proper identification each time that they arrive at the center.  If an individual is not listed on this form, a telephone call WILL NOT be sufficient to release the child to that individual.

Mother’s Signature _______________________

Father’s Signature _______________________

Child’s Name ___________________________

Please Print: ________________________________________________________________ Name           Relation to Child         Address       Phone (Home, Work, Cell)

________________________________________________________________ Name           Relation to Child         Address       Phone (Home, Work, Cell)

________________________________________________________________ Name           Relation to Child        Address        Phone (Home, Work, Cell)

________________________________________________________________ Name           Relation to Child        Address        Phone (Home, Work, Cell)

________________________________________________________________ Name           Relation to Child        Address        Phone (Home, Work, 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