Youth Program Pickup Authorization Form
Authorize a designated person to pick up your child from the youth program. Please complete all fields for operational use.
Parent/Guardian Full Name
*
First Name
Last Name
Parent/Guardian Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian Email Address
*
example@example.com
Youth Participant Full Name
*
First Name
Last Name
Youth Participant Program or Group Name
*
Authorized Pickup Person Full Name
*
First Name
Last Name
Authorized Pickup Person Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Authorized Pickup Person Relationship to Youth
*
Please Select
Parent
Guardian
Sibling
Relative
Family Friend
Other
Pickup Authorization Details / Notes
I confirm the person listed above is authorized to pick up the youth participant for this program.
*
Yes, I authorize this pickup
Submit Authorization
Should be Empty: