Please complete the following Pick-up Authorization form for your 4-year-old student.

Student's Name

First Name

Last Name

Parent/Guardian's Name

First Name

Last Name

Phone

(###)

###

####

Email

Authorized Person #1

First Name

Last Name

Relationship

Phone

(###)

###

####

Email

Authorized Person #2

First Name

Last Name

Relationship

Phone

(###)

###

####

Email

Authorized Person #3

First Name

Last Name

Relationship

Phone

(###)

###

####

Email

Name(s) of person NOT allowed to pick up my child.

Appropriate paperwork, such as a divorce decree, will need to be submitted if a parent is not allowed to pick up the student.