STUDENT PICK-UP AUTHORIZATION 22/23

STUDENT PICK-UP AUTHORIZATION

SY2022-2023
STUDENT'S NAME*

First NameLast Name
GRADE*
THE FOLLOWING ADULTS ARE AUTHORIZED TO PICK UP MY CHILD FROM SCHOOL:
PARENT/GUARDIAN (1):*

First NameLast Name
CELL PHONE #:*

Area CodePhone Number
WORK PHONE#:*

Area CodePhone Number
PARENT/GUARDIAN (2):

First NameLast Name
CELL PHONE#:

Area CodePhone Number
WORK PHONE#:

Area CodePhone Number
PERSON(S) OTHER THAN PARENT/GUARDIAN AUTHORIZED TO PICK UP MY CHILD:
NAME OF PERSON #1

First NameLast Name
Phone Number

Area CodePhone Number
RELATIONSHIP:

GRANDPARENTFAMILY FRIENDDAYCARE PROVIDERRELATIVE-OTHER
NAME OF PERSON #2 (OPT)

First NameLast Name
Phone Number

Area CodePhone Number
RELATIONSHIP:

GRANDPARENTFAMILY FRIENDDAYCARE PROVIDERRELATIVE-OTHER
NAME OF PERSON #3 (OPT)

First NameLast Name
Phone Number

Area CodePhone Number
RELATIONSHIP:

GRANDPARENTFAMILY FRIENDDAYCARE PROVIDERRELATIVE-OTHER
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