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Pick-Up Authorization & Medical Emergency Contacts

Student's Name:

Answer required for "Student's Name:"

Complete information for each contact and indicate whether you authorize this person to pick-up your child, and whether this person is an emergency contact in case we can't reach you.

** Please inform the people on the list that we will ask for identification if they are unfamiliar to us **

First Person

Name:

Answer required for "Name:"

Address:

Answer required for "Address:"

Phone Number:

Answer required for "Phone Number:"

Relation to the child:

Answer required for "Relation to the child:"

I authorize the person above to (check appropriate boxes):

Answer required for "I authorize the person above to (check appropriate boxes):"

drop off and pick-up my child

be contacted in case of emergency and care for my child if I can't be reached.

Second Person

Name:

Answer required for "Name:"

Address:

Answer required for "Address:"

Phone Number:

Answer required for "Phone Number:"

Relation to the child:

Answer required for "Relation to the child:"

I authorize the person above to (check appropriate boxes):

Answer required for "I authorize the person above to (check appropriate boxes):"

drop off and pick-up my child

be contacted in case of emergency and care for my child if I can't be reached.

Third Person

Name:

Answer required for "Name:"

Address:

Answer required for "Address:"

Phone Number:

Number Required

Relation to the child:

Answer required for "Relation to the child:"

I authorize the person above to (check appropriate boxes):

Answer required for "I authorize the person above to (check appropriate boxes):"

drop off or pick-up my child

be contacted in case of emergency and care for my child if I can't be reached.

If you want to name more than three authorized persons, fill out the form a second time.