This%form%will%be%distributed%to%the%homeroom%teacher,%EDC,%%
&%Wednesday’s%After%School%Tutoring%Program%as%appropriate.%
This%form%is%optional --%If%you%anticipate%parent/guardians%may%not%be%able%to%pick%up%your%child,%
this%form%provides%staff%with%additional%pick-up%authorizations.%%%%
Student%Name:%________________________________________________%% Grade:%______________%
If%this%information%is%the%sa m e %fo r%sib lin g s,%p le a se% ind ic a te%names/grades%below--%
Student%Name:%________________________________________________% Grade:%______________%
Student%Name:%________________________________________________% Grade:%______________%
I"give"authorizatio n"for "any "of"the"fo llowin g"ind ividu als"to"pic k"up "m y"child."
(Individuals%should%be%pre pare d%w ith%pho to%ID)." %"
Cell:%%%%%(% %)% %%%%-%
Home:%(% %) -%
Alternate:%(% %)% %%%%%%%%%-%
Cell:%%%%%(% %)% %%%%-%
Home:%(% %) -%
Alternate:%(% %)% %%%%%%%%%-%
Cell:%%%%%(% %)% %%%%-%
Home:%(% %) -%
Alternate:%(% %)% %%%%%%%%%-%
Cell:%%%%%(% %)% %%%%-%
Home:%(% %) -%
Alternate:%(% %)% %%%%%%%%%-%
Cell:%%%%%(% %)% %%%%-%
Home:%(% %) -%
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Additional%information%(optional):%%
_________________________________________________________________________________________________________%
___________________________________________________________________________________________________________________________%
___________________________________________________________________________________________________________________________%
Parent%Name%(print):%_____________ ___ ___ ___ __ ___ ___ ___ ___ ____________%
Parent%Signature:%____________________________________________% Date:%__________________________%
Please%resubmit%this%form%as%appropriate%as%information%ch a n ge s%d u r ing %th e %sc h oo l%y ea r.%
OLG!School!
2021-2022!Pick-Up!Authorization!
Grades!K-8!
click to sign
signature
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