addendum PICK-UP authorization FORM

(If you would prefer to fill out a paper Addendum Pick-Up Authorization Form, Please see below to download PDF.)

Child's Name

First Name

Last Name

I authorize the following responsible person not currently listed on my Emergency Form to pick up my child from School.

For how long do you authorize this person to pick up your child?

Today Only

1-3 Days

One Week

For the Rest of this School Year (I will add this person to my Emergency Form)

Name of Authorized Person

First Name

Last Name

Authorized Person's Phone Number

(###)

###

####

Relationship to Child

Please Note

• The authorized person MUST be at least 16 years old. • The aforementioned child will NOT be allowed to leave the School facility with anyone not authorized by the parent of the child. • The authorized person may receive the child in person and WILL be required to provide identification to Prime staff member. • Your child will not be handed over to persons who do NOT present an acceptable ID upon request. • If the person picking up the child appears to be under the influence of alcohol or drugs, your child will not be released. Another authorized person on your emergency form will be called to pick up both the child and the adult. • Only the registered parent or guardian is allowed to complete this authorization form. • You MUST provide your parent code and your signature for this authorization form to be accepted by the School.

Parent/Guardian Name

First Name

Last Name

Parent/Guardian's Phone Number

(###)

###

####

Parent Code

Parent/Guardian Signature

I agree that writing my full names herein will be my legal signature for purposes of using this online Prime Foundation Montessori Addendum Pick Up Authorization Form, this e-signature will have the same effect as if I had signed my name or initials manually.

Today's Date

MM

DD

YYYY

If you would prefer to fill out a paper Addendum Pick-Up Authorization Form, please download the PDF below.

Addendum Pick-Up Authorization Form PDF

addendum PICK-UP authorization FORM

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