Pick Up Authorization
Please provide us the name and contact information for the approved individual who will be picking up your student(s). This form is to be used for any instance when the parent/guardian is not picking up the student(s).
Your Name
First Name
Last Name
Name of approved individual who can pick up your student(s).
First Name
Last Name
Phone Number of Approved Individual
Please enter a valid phone number.
Format: (000) 000-0000.
Date that this approved individual will be picking up my student(s).
-
Month
-
Day
Year
Date
Is this approved individual permitted to pick up your student(s) at any date/time in the future?
Yes, this approved individual has my blanket permission to pick up at any date/time for the remainder of this school year.
No, I will inform the school when any additional approved pick-ups will be authorized.
Please list student(s) names.
Please sign.
Submit
Should be Empty: