Consent for Drop Off/Pick Up

Consent for Drop Off/Pick Up
I give permission for First Name Last Name with phone number Phone Number to pick up/drop off my child: Child First Name Child Last Name .
Initial here if it is OK to discuss parent education/treatment notes with the above child.*

Clear
Initial Here
Signature

Clear
I understand that unless otherwise indicated, this information will be used only for treatment or educational purposes such as assessments, curriculum programming and coordination of services. I also understand that the agency receiving this information will be responsible for the confidentiality of this information.
Parent Name

First NameLast Name
Signature

Clear
Date

MonthDayYear
Date
Should be Empty: