SummerStage 2017 Pick-Up Authorization Form
To ensure the safety of our children, Arc Stages will not allow any child to leave camp with anyone that does not have prior parental authorization. Please indicate below the names of those that you authorize to pick up your child from the program. If, at some point during camp, you wish to have someone pick up your child that is not on this list, please send a signed note with your child to camp. If you would like to give your child permission to self-dismiss from Arc Stages, please complete the space at the bottom. Thank you!
Child First Name
Your answer
Child Last Name
Your answer
SummerStage Session Attending:
Parent 1 Name
Your answer
Parent 1 Phone #
Your answer
Parent 2 Name
Your answer
Parent 2 Phone #
Your answer
In addition to the parents listed above, I authorize the following person/people to pick up my child from Arc Stages SummerStage 2017:
Name & Relationship to Actor:
Your answer
Name & Relationship to Actor:
Your answer
Name & Relationship to Actor:
Your answer
Name & Relationship to Actor:
Your answer
Name & Relationship to Actor:
Your answer
Name & Relationship to Actor:
Your answer
Electronic Signature
Your answer
SELF-DISMISSAL: If your child will be walking to and/or from camp, they must check in with an Arc Stages staff member in the morning, and sign out the end of the camp day. If you would like to give your child permission to self-dismiss at the conclusion of the camp day, Arc Stages will not be responsible for your child once they leave the Arc Stages facility.
To give your child permission to self-dismiss, please type this sentence in the space below: "I give permission for my child ___________ to self-dismiss from Arc Stages."
Your answer
Electronic Signature
Your answer
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Additional Terms