High Ability Student Name: ______________________________________________ G# ______________________
HIGH ABILITY PROGRAM
GRAMBLING STATE UNIVERSITY
AUTHORIZED Transportation/Pick Up Person Release: Grambling State University assumes responsibility for the
welfare of its students. The University requires written permission for High Ability students to be released to anyone other
than parents or guardians. THIS FORM MUST BE COMPLETED in order for an alternate person to pick up High Ability
students in the event that a parent/guardian is unable to do so (on the last day of the program, during weekends, or if
the student is dismissed for medical or behavioral reasons). This form covers pick-up from the residential hall in which the
High Ability student is being housed. THIS FORM MUST BE COMPLETED BY THE FIRST DAY OF THE PROGRAM. WE WILL
NOT ACCEPT A TELEPHONE CALL, EMAIL, OR A FAXED COPY OF THIS FORM AUTHORIZING RELEASE OF A HIGH
ABILITY STUDENT TO ANOTHER PERSON ON THE DAY OF DEPARTURE.
PLEASE CHECK ONE. COMPLETE FORM AND PRINT & SIGN NAME BELOW.
I hereby give Grambling State University High Ability Program permission to release my child to the
authorized person(s) named below.
Name: _____________________________________________________________________________________________
Relationship to High Ability Student: _____________________________________________________________________
Home Telephone: _____________________________________ Cell/Work Phone: _______________________________
Name: _____________________________________________________________________________________________
Relationship to High Ability Student: _____________________________________________________________________
Home Telephone: _____________________________________ Cell/Work Phone: _______________________________
Name: _____________________________________________________________________________________________
Relationship to High Ability Student: _____________________________________________________________________
Home Telephone: _____________________________________ Cell/Work Phone: _______________________________
I do not give permission for my child to be released to anyone except parents or legal guardian.
Parent/Guardian Name: ______________________________________________ Date: ___________________________
Signature: _________________________________________________________ Phone: __________________________
We require picture ID of all individuals picking up High Ability students on the last day of the program, during weekends,
as well as early dismissals. Thank you for your cooperation.
HA-061213
Authorization for Transportation/Pick Up Form
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