Fillable Child Pick-up Authorization my child(ren) to the person(s)

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Child Pick-up Authorization my child(ren) to the person(s)

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The Child Pick-up Authorization my child(ren) to the person(s) form is 1 page long and contains:

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Country of origin: OTHERS
File type: PDF

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Child Pick-up Authorization
I, _____________________________authorize ________________________________(site name)Childcare to release
my child(ren) to the person(s) designated. This is in consonance with the
________________________________(site name)Emergency Operations Plan.
Student’s Name
Designated Custodians Name and
Relationship
Your Signature Relationship Date
Print Name
Address
Home Phone Work phone Cell Phone
Please Note: Please print clearly. Parents are to designate themselves as custodians and
any additional friends, neighbors or relatives you would be willing to release your child to
in the event the children must evacuate from the site or center. This form is a required
part of the Emergency Preparedness plans that all licensed childcare facilities are required
to have in place.
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Child Pick-up Authorization my child(ren) to the person(s)

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Completed 10 March 2021

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