Program Tool
Program Tool

Sample Release / Pickup Authorization

Virtual Lab School School-Age Safe Environments Lesson 4 Learn Sample Release / Pickup Authorization
Program Tool
WWW.VIRTUALLABSCHOOL.ORG
ACTIVITY ID: 21926
Name
Certifier
Date
Release/Pick-up Authorization

I understand that my child will not be permitted to leave with anyone other than the person(s) I have listed below. I give permission for the following person(s) to pickup my child from the school-age program:

Child's name:
Authorized person(s) for release/pick-up:
My relationship to the child:
Signature:
Date:

 

Release/Pick-up Authorization

I understand that my child will not be permitted to leave with anyone other than the person(s) I have listed below. I give permission for the following person(s) to pickup my child from the school-age program:

Child's name:
Authorized person(s) for release/pick-up:
My relationship to the child:
Signature:
Date: