2018 PICK UP AUTHORIZATION
Please list any individual who is authorized to pick up your child, including yourself. Each authorized person must be at least 16 years of age.

The below-named participant will not be permitted to leave West Quad with anyone who is not listed below. Authorized individuals must pick up children in person and will be requested to show identification to MMSS staff. Participants will not be released to persons who fail to provide acceptable identification upon request.

West Quad is located at 541 Thompson St., Ann Arbor, MI. ALL STUDENTS MUST RETURN TO WEST QUAD BY 9:00PM UNLESS OTHERWISE ARRANGED WITH PROGRAM COORDINATOR.

Parent Name *
Your answer
Parent E-mail Address *
Your answer
Participant Name *
Your answer
Name of authorized person(s): *
Your answer
Date of pick-up: *
Your answer
Time of pick-up: *
Your answer
Time of Return: *
All students must be returned to West Quad before 9:00pm unless staying over night on the weekend, or otherwise arranged with counselor and program coordinator.
Your answer
The following individuals are NOT permitted to pick up my child:
(These individuals are considered UNAUTHORIZED. Please include a brief description of the individual and the relationship to the participant.)
Your answer
Additional Comments
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I certify that all of the information above is to the best of my knowledge and belief true, correct and complete. *
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