Authorization for Release Form

We understand that children may be picked up by adults, other than their parent and/or guardian. In order to protect your child, we are asking that you let us know, in advance, if you will have someone picking your child up from school. You may pre-authorize adults by completing the information below.

Adults who have your authorization and are listed on this or a previous release form will need to
present a current Photo ID to the teacher at time of dismissal. Please give this information to the authorized person.

Child’s Name:

Grade:

Child’s Name:

Grade:

Child’s Name:

Grade:

Child’s Name:

Grade:

Please list any additional adults who will beauthorized to pick up your child. For example: step
parents, siblings, grandparents, childcare helpers, colleagues, carpool, etc.

Authorized Pick Up #1:

Relationship:

Cell Phone:

Authorized Pick Up #1:

Relationship:

Cell Phone:

Authorized Pick Up #1:

Relationship:

Cell Phone:

Authorized Pick Up #1:

Relationship:

Cell Phone:

I authorize the above person(s) to pickup my child from school.

I understand this permission will be in place until I communicate a change, in writing, to the school.

Se você é humano, deixe este campo em branco.

Authorization for Release Form

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