Authorized Pickup and Emergency Contact Authorization Form

Collects parent/guardian consent, authorized pickup adults, and emergency contacts for child-release compliance and emergency response.

Child and Program Information

• Child's Full Name
• Child's Date of Birth
  Collect only if needed to match the child to an existing enrollment record.
• Program / Site Name
• Class / Room / Group

Parent or Legal Guardian

• Parent / Legal Guardian Full Name
• Relationship to Child
• Phone Number
• Email Address

Authorized Pickup Adults

• Authorized Pickup Adults
• Pickup Password or Phrase
  Optional. If used by the program, this should be shared only with authorized adults.
• Require Photo ID at Pickup?
• Additional Pickup Instructions
  Include only necessary instructions, such as time restrictions or approved release procedures.

Emergency Contacts

• Emergency Contacts
• May staff leave a voicemail or text if unreachable?

Custody and Release Restrictions

• Are there any custody orders or release restrictions?
• Restriction Summary
  Provide only the minimum necessary details for staff to follow the restriction.
• Upload Supporting Documentation
  Optional. Upload only if required by your program's policy.

Consent, Attestation, and Submission

• I authorize the individuals listed above to pick up my child and understand the program may verify identity before release.
• I authorize the program to contact the emergency contacts listed above if I cannot be reached in an emergency.
• I confirm the information provided is accurate and I will notify the program promptly of any changes.
• Parent / Legal Guardian Signature
• Date Signed
• What happens after I submit
  After submission, the form is recorded for staff review and used for child-release and emergency contact purposes. Keep your contact list updated whenever pickup permissions change.