KDO Elementary Safety Form 2026-2027

Form Status:
KDO Elementary Safety Form
Elementary Student Pick-Up Authorization

Dear Elementary Parents,

At KDO Academy, the safety and security of every student is a top priority.

Please complete this form listing the full name and address of each individual authorized to pick up your child(ren).

For your child’s protection:
- A valid pick up pass for KDO Academy
- A valid photo ID will be required at pick-up. Note: The information on the ID must match what is provided on this form.
- Students will only be released to individuals listed on this form.
  If someone arrives who is not listed, your child will not be released. We will contact you directly for verification before making any decisions.
We strongly encourage you to think through any family members, friends, or emergency contacts you may call upon during the year and include them now.

Complete and accurate information helps us ensure your child is released only to individuals you have approved.

Thank you for partnering with us to maintain a safe environment for all students.
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 Cell #1 Number:*
Format: (000) 000-0000.
Parent's Cell #2 Number:
Format: (000) 000-0000.
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 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:*
example@example.com
Should be Empty: