Authorization Form

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Child's Name: _______________________________________________

Main pick-up person: 

Name: _____________________________________________________ 

Address: ___________________________________________________ 

Relationship: _______________________________________________ 

Phone: _________________ __________________ 

Person(s) 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 or a phone call. 

Mother's Signature: _______________________ Date: ______________ 

Father's Signature: ________________________ Date: _____________