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Authorization for Student Pick-Up

The following individuals are over 18 years of age and are authorized to pick-up my child from school with proper identification.*

Answer Required

Yes

Student Name*

Answer Required

Name of Authorized Individual 1*

Answer Required

Relationship to Student *

Answer Required

Contact Phone *

Number Required

Name of Authorized Individual 2

Answer Required

Relationship to Student

Answer Required

Contact Phone

Number Required

Name of Authorized Individual 3

Answer Required

Relationship to Student

Answer Required

Contact Phone

Number Required

Name of Authorized Individual 4

Answer Required

Relationship to Student

Answer Required

Contact Phone

Number Required

Name of Authorized Individual 5

Answer Required

Relationship to Student

Answer Required

Contact Phone

Number Required

I authorize my printed name below to serve as my signature. *

Answer Required

Yes

Parent/Guardian Name*

Answer Required

Date*

Answer Required