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)
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Name Relation to Child Address Phone (Home/Cell)
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Name Relation to Child Address Phone (Home/Cell)
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Name Relation to Child Address Phone (Home/Cell)
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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.
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Name Relation to Child Address
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Name Relation to Child Address
