| CHILD PICK UP AUTHORIZATION Name:_______________________________________ Address:_____________________________________ Relationship to Child:___________________________ Phone #:________________ Additional persons who may pick up child/children on a less frequent basis: Name:_____________________________________________ Address:____________________________________________ Relationship to Child:__________________________________ Phone #:___________________ ------------------------------------------------------------------------------------------------------------- Name:_______________________________________________ Address:______________________________________________ Relationship to Child::___________________________________ Phone #:____________________ Any persons NOT authorized to pick up my child/children: ________________________________________________________________________ Any persons unfamiliar to me will be required to show proof of identification. Under NO circumstances will the child be released to anyone other than those listed above without WRITTEN permission from the parent. Mother�s Signature_________________________________________Date__________ Father�s Signature__________________________________________Date__________ |
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