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Authorized Pick-up Form Child Name: ___________________________________________________________________ Grade Sept. ’18 _________________________________________________________________ Parent Name: __________________________________________________________________ I authorize the following people to pick up my child at Covenant Church. Please include names of both parents as well as any other authorized adults. Please note that drivers must show identification to pick up child. List all possibilities (i.e. grandparents, neighbors, family) Name: ________________________________________ Phone #_________________________ Relationship to child: ____________________________________________________________ Name: ________________________________________ Phone #_________________________ Relationship to child: ____________________________________________________________
Name: ________________________________________ Phone #_________________________ Relationship to child: ____________________________________________________________
Name: ________________________________________ Phone #_________________________ Relationship to child: ____________________________________________________________
Name: ________________________________________ Phone #_________________________ Relationship to child: ____________________________________________________________
Name: ________________________________________ Phone #_________________________ Relationship to child: ____________________________________________________________
Parent’s Signature: ____________________________ Date: ____________________________
