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STUDENT PICK-UP AUTHORIZATION
SY2024-2025
STUDENT'S NAME
*
First Name
Last Name
GRADE
*
THE FOLLOWING ADULTS ARE AUTHORIZED TO PICK UP MY CHILD FROM SCHOOL:
PARENT/GUARDIAN (1):
*
First Name
Last Name
CELL PHONE #:
*
-
Area Code
Phone Number
WORK PHONE#:
*
-
Area Code
Phone Number
PARENT/GUARDIAN (2):
First Name
Last Name
CELL PHONE#:
-
Area Code
Phone Number
WORK PHONE#:
-
Area Code
Phone Number
PERSON(S) OTHER THAN PARENT/GUARDIAN AUTHORIZED TO PICK UP MY CHILD:
NAME OF PERSON #1
First Name
Last Name
Phone Number
-
Area Code
Phone Number
RELATIONSHIP:
GRANDPARENT
FAMILY FRIEND
DAYCARE PROVIDER
RELATIVE-OTHER
NAME OF PERSON #2 (OPT)
First Name
Last Name
Phone Number
-
Area Code
Phone Number
RELATIONSHIP:
GRANDPARENT
FAMILY FRIEND
DAYCARE PROVIDER
RELATIVE-OTHER
NAME OF PERSON #3 (OPT)
First Name
Last Name
Phone Number
-
Area Code
Phone Number
RELATIONSHIP:
GRANDPARENT
FAMILY FRIEND
DAYCARE PROVIDER
RELATIVE-OTHER
Signature
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: