2021-2022 Miriam Academy Pick Up Authorization

Student's Name

First Name Last Name

We require a list of all persons, (family members, carpool drivers, friends, etc.) who may pick up your student from school. Please list the names and telephone numbers of those people you authorize to pick up your student.

If an unauthorized person will be picking up your student or your student will be going home with another student, the student's parent must notify the office via email or over the phone. Please note, identification may also be requested by the staff at pick up. If any information on this list changes throughout the year, please resubmit this form.

Names of persons, other than parents, authorized to pick up my student at Miriam Academy include:

Person 1

First Name Last Name

Relationship to student

Phone Number

Area Code Phone Number

Person 2

First Name Last Name

Relationship to student

Phone Number

Area Code Phone Number

Person 3

First Name Last Name

Relationship to student

Phone Number

Area Code Phone Number

Person 4

First Name Last Name

Relationship to child

Phone Number

Area Code Phone Number

Parent/Guardian signature *

First Name Last Name

Date *

Month Day Year

Student Birthdate *

Enter the message as it's shown *

Pick-Up Authorization