PICK UP AUTHORIZATION FORM

We will not release your child to “Anyone” unless written authorization is provided.  All persons must show picture identification to staff.

Child's Name: ____________________ 

NAME: ____________________  RELATIONSHIP: ___________
 

NAME: ____________________  RELATIONSHIP: ___________
 

NAME: ____________________  RELATIONSHIP: ___________
 

NAME: ____________________  RELATIONSHIP: ___________
 

NAME: ____________________  RELATIONSHIP: ___________

 

___________________________________     ______________

Parent/Guardian’s Signature                              Date

NOTE: We will not release your child to “Anyone” unless written authorization is provided.  All persons must show picture identification to staff.