2019-2020 Authorized Release List
This form provides Good Shepherd Lutheran Preschool with the names and contact information for people authorized to pick up your child from school and other emergency information.
Email address *
Child's First Name *
Your answer
Child's Last Name *
Your answer
Child's 2019-2020 Class *
Families with Multiple Students
If you are submitting forms for multiple students from the same family, you may list the names and classes of other students below if the information on this form is the same for all students in the family. You do not need to submit this form again for the students listed below.
Your answer
Parent/Guardian Information
Parents/guardians listed are assumed to have pick-up authorization unless a custody arrangement is provided.
Adult 1 - Full Name *
Your answer
Adult 1 - Relationship to Child *
Adult 1 - Occupation *
Your answer
Adult 1 - Mobile Phone *
Your answer
Adult 1 - Other Phone
Your answer
Adult 1 - Email Address *
Your answer
Adult 2 - Full Name
Your answer
Adult 2 - Relationship to Child
Adult 2 - Occupation
Your answer
Adult 2 - Mobile Phone
Your answer
Adult 2 - Other Phone
Your answer
Adult 2 - Email Address
Your answer
Custody Arrangement *
If yes, please provide a copy of the arrangement for your child's file.
Emergency Contact Information
GSLP must have two phone numbers for emergency contacts who can be given the details of any emergency situation and who can make decisions concerning the child should GSLP be unable to reach the child's parents/guardians. One phone number must be an out-of-area number (i.e., a phone number that does not have a 202, 301, or 240 area code).
Local Contact Name
Your answer
Local Contact Phone Number
Your answer
Out-of-Area Contact Name
Your answer
Out-of-Area Contact Phone Number
This phone number must not have a 202, 301, or 240 area code.
Your answer
Child Release Authorization
The following persons (must be over age 16) have permission to pick up the above-named child from GSLP. You must list at least two people. Additional people can be added later in the Preschool Office. Parents listed above are assumed to have pick-up authorization unless a custody arrangement is provided and so should not be listed below.
Pick-Up Name 1 *
Your answer
Pick-Up Phone 1 *
Your answer
Pick-Up Name 2 *
Your answer
Pick-Up Phone 2 *
Your answer
Pick-Up Name 3
Your answer
Pick-Up Phone 3
Your answer
Pick-Up Name 4
Your answer
Pick-Up Phone 4
Your answer
Pick-Up Name 5
Your answer
Pick-Up Phone 5
Your answer
Pick-Up Name 6
Your answer
Pick-Up Phone 6
Your answer
Pick-Up Name 7
Your answer
Pick-Up Phone 7
Your answer
Pick-Up Name 8
Your answer
Pick-Up Phone 8
Your answer
Pick-Up Name 9
Your answer
Pick-Up Phone 9
Your answer
Emergency Transportation
In emergencies requiring immediate medical attention, 9-1-1 help will be summoned and your child will be taken to the nearest hospital emergency room. You will be contacted as soon as possible. If permitted, a staff member will stay with your child until you arrive. Your typed full name below constitutes your electronic signature and authorizes the Good Shepherd Lutheran Preschool staff to have your child transported and treated by medical personnel.
Electronic Signature *
Type your full name below to sign this form.
Your answer
Today's Date *
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YYYY
A copy of your responses will be emailed to the address you provided.
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