Authorized Pickup and Emergency Contact Authorization Form

Collects guardian consent, authorized pickup adults, emergency contacts, and release restrictions for child-release compliance in childcare settings.

Child and Program Information

• Child's Full Name
• Child's Date of Birth
• Program / Classroom Name
• Authorization Effective Date

Parent or Legal Guardian Information

• Parent / Legal Guardian Full Name
• Relationship to Child
• Phone Number
• Email Address
• Consent to collect and store the personal information provided on this form for child-release and emergency contact purposes

Authorized Pickup Adults

• Authorized Pickup Adults
• Accepted ID Types for Pickup Verification

Pickup Restrictions and Custody Orders

• Are there any pickup restrictions, custody orders, or court directives?
• Describe the restriction and any required release instructions
• Individuals who must not be released the child

Emergency Contacts

• Emergency Contacts

Consent, Attestation, and Signature

• I confirm that the information provided is accurate and that the listed individuals are authorized according to the instructions above.
• Parent / Legal Guardian Signature
• Signature Date