Authorized Student Pick-Up List
It is school policy that children will be released only to their parent/guardian or other authorized persons at dismissal or from the After School program. Please provide the contact information for each authorized individual. Thank you for keeping this information updated with our school office. PLEASE COMPLETE ONE FORM PER STUDENT. NOTE: This form does not roll over to the next school year, a new Authorization Form must be completed for each school year per student.
Email address *
Student Name (first and last) *
Your answer
Classroom Name *
Your answer
Parent/Legal Guardian name (first and last) *
Your answer
School Year (EG: 2019-20) *
Your answer
Full Name and Phone Number of Authorized Individual *
Your answer
Full Name and Phone Number of Authorized Individual
Your answer
Full Name and Phone Number of Authorized Individual
Your answer
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