Emergency and Pick-Up Authorization


Child's Name:

Parent / Guardian Name(s):

Street Address:

City: Zip Code:

Cell Phone: Home Phone:


Employer: Work Phone:

Employer Address:

City: Zip Code:

Typical Working Hours:


Please list three (3) people we should contact if we are unable to reach the parent(s) or guardian in the event of illness or other emergency. List all persons WHO HAVE YOUR PERMISSION to pick up your child from the center. Anyone not known by the staff will be required to show a picture ID.

Name:

Relationship: Phone Number:

Address:

City: Zip Code:


Name:

Relationship: Phone Number:

Address:

City: Zip Code:


Name:

Relationship: Phone Number:

Address:

City: Zip Code:


Is anyone prohibited by law from picking up your child?

Name and relation to child:

Legal documentation must be furnished. Have you given us a copy?

Leave this empty:

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Signature Certificate
Document name: Emergency and Pick-Up Authorization
lock iconUnique Document ID: 261c1e72908878c180b53444179bd11a9b24460d
Timestamp Audit
April 19, 2021 9:50 am CDTEmergency and Pick-Up Authorization Uploaded by Joe Massaro - jmassaro@capeevansville.org IP 96.27.254.146