WRRS CY-09 02/16 INTERNAL USE ONLY
Authorized Pick Up Form
Approved Child Pick Up Information
Child (First/Last Name)
Children need to be signed in/out of our day camps/programs on a daily basis. I authorize my child to:
Only be allowed to leave with the parent(s) indicated below:
The following individuals are authorized to pick up my child (ID is required for pick up):
Is there anyone who is legally NOT authorized to pick up your child? If yes, please contact our Children’s Manager.
Self Sign Out Authorization
Children need to be signed in/out of our day camps/programs on a daily basis. Do you authorize your child (Must be at
least 10 years of age) to sign him/her self in and out of Westside’s day camps and programs.
Although we understand the need/want of parents to give their child the independence of walking/biking home after camp,
we recommend that a parent/guardian sign in and out their child every day. If you have given authorization for your child
to sign themselves in and out, please ensure a safe route home for your child.
Our facility guidelines states that children under 13 years of age must be accompanied at all times while in the facility by a
paid individual 16 years of age or older unless an Un-parented Access Orientation has been completed.
Authorized Pick Up forms must be completed annually and will be kept on file for one year.
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