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Run: Authorized Pickup and Emergency Contact Authorization Form

Use this form to record who may pick up a child, who to call in an emergency, and any custody or release restrictions before the first day of care.

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Child and Program Information

Child's Full Name (required)

Child's Date of Birth

Collect only if needed to match the child to an existing enrollment record.

Program / Site Name (required)

Class / Room / Group

Parent or Legal Guardian

Parent / Legal Guardian Full Name (required)

Relationship to Child (required)

Phone Number (required)

Email Address

Authorized Pickup Adults

Authorized Pickup Adults (required)

Pickup Password or Phrase

Optional. If used by the program, this should be shared only with authorized adults.

Require Photo ID at Pickup? (required)

Additional Pickup Instructions

Include only necessary instructions, such as time restrictions or approved release procedures.

Emergency Contacts

Emergency Contacts (required)

May staff leave a voicemail or text if unreachable? (required)

Custody and Release Restrictions

Are there any custody orders or release restrictions? (required)

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. (required)

Yes No N/A

I authorize the program to contact the emergency contacts listed above if I cannot be reached in an emergency. (required)

Yes No N/A

I confirm the information provided is accurate and I will notify the program promptly of any changes. (required)

Yes No N/A

Parent / Legal Guardian Signature (required)

Date Signed (required)

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.

Get your results

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Email (required)

Your name (optional)

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