Student Pickup Risk Assessment Form
Please provide details about the student's pickup arrangements to help us assess safety and authorization.
Student's Full Name
*
First Name
Last Name
Grade/Class
*
Authorized Pickup Person's Name
*
Relationship to Student
*
Please Select
Parent/Guardian
Sibling
Grandparent
Family Friend
Other
Pickup Method
*
Car
Walking
Public Transport
Bicycle
Other
Pickup Time
*
Hour Minutes
AM
PM
AM/PM Option
Contact Number for Pickup Person
*
Please enter a valid phone number.
Format: (000) 000-0000.
Contact Number for Parent/Guardian
Please enter a valid phone number.
Format: (000) 000-0000.
Special Instructions or Concerns
Staff Assessment/Notes
Submit Assessment
Should be Empty: