Run Authorized Pickup List and ID Verification Form — Free

Child and Program Information

Child's First Name (required)

Child's Last Name (required)

Child's Date of Birth (required)

Used to confirm identity and match enrollment records. Date of birth is collected solely for child identification purposes.

Program / Site Name (required)

Name of the childcare center, after-school program, or daycare site.

Classroom or Group (if applicable)

Enrollment Start Date (required)

Parent or Legal Guardian Submitting This Form

Your Full Legal Name (required)

Your Relationship to the Child (required)

If 'Other', please specify your relationship

Your Primary Phone Number (required)

Your Email Address (required)

Used for confirmation and any updates to this authorization. Collected per our privacy notice.

Type of ID You Will Present at Pickup (required)

Staff will verify your identity against this ID type each time you pick up your child.

Authorized Pickup Adults

Authorized Adult 1 – Full Name (required)

Authorized Adult 1 – Relationship to Child (required)

Authorized Adult 1 – Phone Number (required)

Authorized Adult 1 – ID Type They Will Present (required)

Do you want to add another authorized adult? (required)

Authorized Adult 2 – Full Name

Authorized Adult 2 – Relationship to Child

Authorized Adult 2 – Phone Number

Authorized Adult 2 – ID Type They Will Present

Do you want to add a third authorized adult?

Authorized Adult 3 – Full Name

Authorized Adult 3 – Relationship to Child

Authorized Adult 3 – Phone Number

Authorized Adult 3 – ID Type They Will Present

Pickup Restrictions and Custody Orders

Is there an active custody order, restraining order, or court order affecting who may pick up this child? (required)

Briefly describe the restriction (do not include sensitive legal case numbers here)

Example: 'Biological father John Doe is not permitted to pick up the child per family court order dated MM/YYYY.' A copy of the order must be provided to the site director separately.

Has a copy of the court or custody order been provided to the site director?

List any individuals who are explicitly NOT authorized to pick up this child

Staff will be instructed to deny release to these individuals and contact you immediately.

Any other special pickup instructions or time-based restrictions?

Emergency Contacts

Emergency Contact 1 – Full Name (required)

Emergency Contact 1 – Relationship to Child (required)

Emergency Contact 1 – Phone Number (required)

Is Emergency Contact 1 also authorized for pickup? (required)

If yes, please also add them in the Authorized Pickup Adults section with their ID type.

Emergency Contact 2 – Full Name (optional)

Emergency Contact 2 – Phone Number

Consent, Attestation, and Signature

I attest that all information provided on this form is accurate and complete to the best of my knowledge. (required)

Yes No N/A

I understand that staff will require a valid government-issued photo ID from every person listed on this form, including myself, at each pickup. Release will be denied if ID cannot be verified. (required)

Yes No N/A

I understand that it is my responsibility to notify the site director in writing if I need to add, remove, or modify any authorized pickup adult. Verbal changes will not be accepted. (required)

Yes No N/A

I consent to this program retaining this form and associated records as part of the child's enrollment file for the duration of enrollment and as required by applicable state childcare licensing regulations. (required)

Personal information collected on this form is used solely for child safety and release authorization purposes, consistent with data minimization principles.

Yes No N/A

Date of Submission (required)

Parent / Guardian Signature (required)

By signing, you confirm your legal authority to complete this authorization and your agreement to all statements above.

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Run: Authorized Pickup List and ID Verification Form

Child and Program Information

Parent or Legal Guardian Submitting This Form

Authorized Pickup Adults

Pickup Restrictions and Custody Orders

Emergency Contacts

Consent, Attestation, and Signature

Get your results