Adult Pickup Form

Authorized Adult Pickup Form
Guardian Email (the person filling out this form)
example@example.com
Removing or Adding

This section is to indicate if an adult is being removed as authorized pickup or if they are being added
Removing or Adding
Student Information
Student Name

First NameLast Name
Adult Information:
Adult Name (As it appears on their Government issued ID)

First NameLast Name
Preferred name (if different from legal name)

First NameLast Name
Relationship to Student
E-mail
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Preferred Contact Method (click all that apply)
Additional Information:
Are there any custody arrangements or legal restrictions on this contact?
If yes, please provide details
Legal Guardian Consent
I certify that I am the parent or legal guardian of the child listed on this form. I authorize the individual identified on this form to pick up my child from Play-On Afterschool. I understand that:
- Play-On Afterschool may request a valid government-issued photo ID before releasing my child.
- It is my responsibility to keep this authorization current and notify Play-On Afterschool in writing of any changes.
- Only the individuals authorized by me, or otherwise approved by me in writing, may pick up my child, unless required by law.
Guardian Printed Name

First NameLast Name
Date signed
Should be Empty:

Authorized Adult Pickup Form