Pick-Up Permission Form 24-25

Co-op Pick-Up Permission Form

2024-2025 School Year
Child'sName*

First NameLast Name
Child's Date of Birth*

MonthDayYear
Date
I authorize the following persons to remove my child from the Westport Weston Cooperative Nursery School:

***Please DO NOT include Parents/Legal Guardians on this form
Name of Authorized Person #1/Emergency Contact*

First NameLast Name
Cellphone #:*
Authorized Person #1/Emergency Contact
Relationship to Child:*
Authorized Person #1/Emergency Contact
Name of Authorized Person #2

First NameLast Name
Cellphone #:
Authorized Person #2
Relationship to Child:
Authorized Person #2
Name of Authorized Person #3

First NameLast Name
Cellphone #:
Authorized Person #3
Relationship to Child:
Authorized Person #3
Name of Authorized Person #4

First NameLast Name
Cellphone #:
Authorized Person #4
Relationship to Child:
Authorized Person #4
Name of Authorized Person #5

First NameLast Name
Cellphone #:
Authorized Person #5
Relationship to Child:
Authorized Person #5
The Westport Weston Cooperative Nursery School will not release your child to a person not listed above without written authorization.
Parent's Name*

First NameLast Name
Email*
example@example.com
Date

MonthDayYear
Date
Parent Signature*

Clear
Should be Empty:

Co-op Pick-Up Permission Form