Alternate Pick-Up Person Form
Please provide details of the person authorized to pick up your child.
Child's Full Name
*
First Name
Last Name
Your Full Name (Parent/Guardian)
*
First Name
Last Name
Alternate Pick-Up Person Full Name
*
First Name
Last Name
Relationship to Child
*
Phone Number of Alternate Pick-Up Person
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Authorization
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Additional Notes (if any)
*
Signature of Parent/Guardian
*
Submit
Should be Empty: