Pickup Form
Please complete all sections to authorize emergency, medical, and pickup instructions for your child.
Student Name
*
First Name
Last Name
Parent/Guardian Name
*
First Name
Last Name
Primary Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Secondary Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact #1 - Name / Relationship / Phone
*
Emergency Contact #2 - Name / Relationship / Phone
Primary Care Provider
Relevant Allergies
Relevant Medical Information
Emergency Instructions
Authorized Pickup - 1. Name / Relationship / Phone
Authorized Pickup - 2. Name / Relationship / Phone
Authorized Pickup - 3. Name / Relationship / Phone
Authorized Pickup - 4. Name / Relationship / Phone
Parent/Guardian Signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Submit
Should be Empty: