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
Your Signature Relationship Date
Print Name
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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