pick-up authorization for

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DROP-OFF/PICK-UP AUTHORIZATION FOR _____________________________________(Child’s Name)

The following people are authorized to drop-off or pick-up my child: Name ________________________________________ Phone ___________________________ Name ________________________________________ Phone ___________________________ Name ________________________________________ Phone ___________________________ Name ________________________________________ Phone ___________________________

The following people are NOT authorized to drop-off or pick-up my child: Name ________________________________________ Name ________________________________________

SIGNED _______________________________________ DATE _____________________________