CHILD PICK-UP AUTHORIZATION FORM - Your Personal …
CHILD PICK-UP AUTHORIZATION FORM
Child’s name: _____________
Main pick-up person:
Name: ________________
Address: _______________
Relationship: _____________
Phone: _______________
Additional persons who may pick up child/children on a less frequent basis:
Name: _______________
Address: ______________
Relationship: _____________
Phone: _______________
Name: _______________
Address: ______________
Relationship: _____________
Phone: _______________
any person(s) NOT authorized to pick up my child/children:
________________________________________
Note: Any person unfamiliar to me will be required to show proof of identification. Under NO circumstances will the child be released to anyone other than those listed above without WRITTEN permission from the parent.
Mother's Signature: _______________Date: ________
and / or
Father's Signature: _______________Date: ________
................
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