Authorized Pickup Form
These forms are required for your student to be picked up by another person
Camper's Information
Student Name
*
Parent/Guardian Information
Parent/Guardian
*
First Name
Last Name
Relationship to Child
*
E-mail
*
example@example.com
Cell Phone
*
Home Phone
*
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Authorized Pickup
Parents cannot be listed as emergency contacts. List the name of at least one person who can be contacted in the event of an emergency or illness if you cannot be reached. Any person listed should be able to assist in contacting you. At least one person listed must be within one hour of the center/home, able to take responsibility for the child in case the parent/guardian cannot be contacted and should be at least 18 years of age. The first emergency contact must live no more than 1 hour away and be over the age of 18.
Authorized Pickup #1
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Phone
*
Relationship to Child
*
Authorized Pick Up?
*
Yes
No
Add Additional Authorized Pickup Contact?
*
Yes
No
Authorized Pickup #2
Full Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Phone
*
Relationship to Child
Authorized Pick Up?
*
Yes
No
Signature
*
Date
*
-
Month
-
Day
Year
Date
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SUBMIT
Should be Empty: