Child Pickup Form

Please fill out the following form.

Child"s Name

Multi-line address

Country/Region

Address

City

Zip / Postal code

Parent/Guardian's Name:

Mother

Phone Numbers:

Father

Home

Cell

List the names, addresses and phone numbers of individuals who might be picking up your child in an emergency or when you are unable to pick them up.

Names, Addresses, Phone Numbers:

List the names of anyone who is NOT permitted to pick up your child by court order or otherwise:

NOT PERMITTED

It is the parent/guardian’s responsibility to keep this form current. It is also the parent/guardian’s responsibility to tell the teacher if someone different will be picking up the child other than the person who customarily has the daily responsibility.

I have read, understood and completed this form.

Parent/Guardian Signature

Signature field is empty.

Date

Month

Day

Year

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Child Pickup Form

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