Child Drop Off/Pick up Form

Child's name First Name* Last Name* Today's date Date*

The following adults are authorized to pick up my child from school.

Parent/Guardian #1   First Name   Last Name
Relationship
Phone   Area Code   Phone Number
Email   Email

Parent/Guardian #2   First Name   Last Name
Relationship
Phone   Area Code   Phone Number
Email   Email

Persons other than Parent/Guardian authorized to pick up/drop off my child at school.

Adult #1   First Name   Last Name
Relationship
Phone   Area Code   Phone Number
Adult #2   First Name   Last Name
Relationship
Phone   Area Code   Phone Number
Adult #3   First Name   Last Name
Relationship
Phone   Area Code   Phone Number

In case of a last minute change or addition, you will either:1)send a note for the student's teacher in the morning, authorizing your child's release to the new person and including the dates for which permission is given; 2)email the school to authorize another individual for drop off/pick up. Only email addresses on record for parent/guardian will be accepted.

Note: All persons unfamiliar to Eastgate Academy staff will be required to show identification. Under NO circumstances will a child be released to an unauthorized person without written permission.

Persons NOT authorized to pick up my child: First Name* Last Name*

Parent/Guardian #1 Signature* Date*
Parent/Guardian #2 Signature* Date*

Child Drop off and Pick up Authorization Form