Emergency Contact/Child Release AuthorizationInformation may be added at any time.If information changes, completion of a new form is required. Child's Name * First Name Last Name Child's Date of Birth * MM DD YYYY Child's Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Parent/Guardian #1 Name * First Name Last Name Preferred Phone * (###) ### #### Secondary Phone (###) ### #### Parent/Guardian #1 Address (if different than child) Address 1 Address 2 City State/Province Zip/Postal Code Country Parent/Guardian #2 Name First Name Last Name Preferred Phone (###) ### #### Secondary Phone (###) ### #### Parent/Guardian #2 Address (if different than child) Address 1 Address 2 City State/Province Zip/Postal Code Country PARENT IDENTIFICATION INFO NOTE: I.D. number may be a Social Security Number or other unique identification number. Password should be a word that only the parent/guardian knows. This information will be used to verify parent/guardian identity if the parent/guardian is not known by staff. The parent/guardian is responsible for calling the center to authorize if someone other than those listed on this form picks up their child. Parent/Guardian #1 ID or password: Parent/Guardian #2 ID or password: ADDITIONAL AUTHORIZED PERSONS List any additional authorized persons who may pick up your child. Indicate if a phone call is necessary to the parent prior to pickup. Authorized Person #1 First Name Last Name Preferred Phone (###) ### #### Relationship to child Do you still require a phone call? Yes No Authorized Person #2 First Name Last Name Preferred Phone (###) ### #### Relationship to child Do you still require a phone call? Yes No Authorized Person #3 First Name Last Name Preferred Phone (###) ### #### Relationship to child Do you still require a phone call? Yes No Authorized Person #4 First Name Last Name Preferred Phone (###) ### #### Relationship to child Do you still require a phone call? Yes No ELECTRONIC SIGNATURE Parent/Guardian Name * For the safety of your child, we will request all authorized persons with whom the staff are not familiar to provide photo I.D. at time of pick up. We will not send a child without a text, email, or written note from primary caregiver. First Name Last Name Thank you!
