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.
Yes No
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.
Yes No
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.
Signatures
Parent/Guardian Signature
Authorized Pick Up forms must be completed annually and will be kept on file for one year.
click to sign
signature
click to edit
![]()
