Custody Pickup Authorization and Release Form
Complete this form to authorize a named adult to pick up a child and confirm release details. All information is required for proper authorization and release.
Child's Full Name
*
First Name
Last Name
Date of Birth of Child
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Authorized Adult's Full Name
*
First Name
Last Name
Relationship of Authorized Adult to Child
*
Please Select
Parent
Guardian
Grandparent
Sibling
Other Relative
Family Friend
Other
Date of Authorized Pickup
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time of Authorized Pickup
*
Hour Minutes
AM
PM
AM/PM Option
Authorized Adult's Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Authorized Adult's Email Address
*
example@example.com
Special Instructions for Pickup (if any)
By signing below, I authorize the named adult to pick up the child listed above on the specified date and time, and confirm the release of custody as described.
*
Submit Authorization
Submit Authorization
Should be Empty: