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Run: Authorized Pickup and Emergency Contact Authorization Form

This Authorized Pickup and Emergency Contact Authorization Form collects guardian consent, approved pickup adults, emergency contacts, and any pickup restric...

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Child and Program Information

Child's Full Name (required)

Child's Date of Birth (required)

Program / Classroom Name

Authorization Effective Date (required)

Parent or Legal Guardian Information

Parent / Legal Guardian Full Name (required)

Relationship to Child (required)

Phone Number (required)

Email Address

Consent to collect and store the personal information provided on this form for child-release and emergency contact purposes (required)

Yes No N/A

Authorized Pickup Adults

Authorized Pickup Adults (required)

Accepted ID Types for Pickup Verification (required)

Pickup Restrictions and Custody Orders

Are there any pickup restrictions, custody orders, or court directives? (required)

Describe the restriction and any required release instructions (required)

Individuals who must not be released the child

Emergency Contacts

Emergency Contacts (required)

Consent, Attestation, and Signature

I confirm that the information provided is accurate and that the listed individuals are authorized according to the instructions above. (required)

Yes No N/A

Parent / Legal Guardian Signature (required)

Signature Date (required)

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Email (required)

Your name (optional)

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