KDO Academy Safety Form

Form Status:
KDO Elementary Safety Form
Please read the safety information and complete the form
Dear Parents of our elementary students:

We take the security and care of your child seriously. Kindly fill out this form with the names and addresses of each person who has permission to pick up your child(ren). The teacher will check the photo ID against the information you provide. Please understand, if the person is not listed, then we will not give your child to them. We will have to call you directly for permission. Think about the family members you may potentially call to pick up your child. Please list all info completely on this form. This ensures your child is with someone you trust!

KDO Academy Board
Student's Name:*

First NameLast Name
Student Grade:*
Student's Name:

First NameLast Name
Student Grade:
Student's Name:

First NameLast Name
Student Grade:
Parent's Name:*

First NameLast Name
Parent's Home Phone Number:*

Area CodePhone Number
Parent's Cell #1 Number:

Area CodePhone Number
Parent's Cell #2 Number:

Area CodePhone Number
List all names of persons who may pick up child(ren): If you do it each week, don’t list your name. Start with spouse's name, and then anyone else (siblings, relatives, friends, neighbors) you may ask to pick up. In this day and age, we don’t want to assume anything!
Authorized Person to Pick up:

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Authorized Person to Pick up:

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Authorized Person to Pick up:

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Authorized Person to Pick up:

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
I will allow the persons I named to pick up my child and will advise of any needed changes when necessary. I understand a typed and submitted form is considered 'signed'.*

I agree to the above listed person(s) to pick up my child
Agreed by Parent:*

First NameLast Name
Today's Date:*

MonthDayYear
Date
E-mail Address:*
Should be Empty:

KDO Elementary Safety Form