Student Pick Up Authorization Form 25-26
Beginning of the Year Pick Up Authorization Update
Student Name:
*
First Name
Last Name
Student Birthday
*
/
Month
/
Day
Year
Pickup Authorization Form
Complete Pickup Authorizations and Emergency Contact Information
First Parent/ Guardian's Name
*
First Name
Last Name
Relationship to child
*
Cell Phone
*
-
Area Code
Phone Number
Work Phone
-
Area Code
Phone Number
Second Parent/ Guardian's Name
First Name
Last Name
Relationship to child
Cell Phone
-
Area Code
Phone Number
Work Phone
-
Area Code
Phone Number
Additional Pickup Authorizations
Complete the information below for individuals who have permission to pick up your child. The persons below MUST be at least 18 years of age. Include people who may not be listed in the application who have permission to pickup your child. A separate authorization must be made for each child.
Name
First Name
Last Name
Phone
-
Area Code
Phone Number
Relationship to child
Name
First Name
Last Name
Phone
-
Area Code
Phone Number
Relationship to child
Name
First Name
Last Name
Phone
-
Area Code
Phone Number
Relationship to child
Name
First Name
Last Name
Phone
-
Area Code
Phone Number
Relationship to child
Name
First Name
Last Name
Phone
-
Area Code
Phone Number
Relationship to child
Emergency Contact Information
In the event the primary parent(s) and/or guardian(s) cannot be reached, please list below who should be contacted.
Emergency Contact #1
First Name
Last Name
Phone
-
Area Code
Phone Number
Relationship to child
Emergency Contact #2
First Name
Last Name
Phone
-
Area Code
Phone Number
Relationship to child
No Pick Up List
If there is anyone who is NOT allowed to pick up your child(ren), please list name(s) below.
No Pick Up List
Submit
Should be Empty: