Pick-up Permission Form

Childs Name:______________________________________________

Please list below the people who have Permission to pick up your child.
Name: ___________________ Phone: __________________ Relationship: _______________
Name: ___________________ Phone: __________________ Relationship: _______________
Name: ___________________ Phone: __________________ Relationship: _______________

*ALL PERSONS MUST SHOW PHOTO ID AND YOU MUST GIVE ADVANCE
NOTICE OF PICK-UPS BY DESIGNATED PERSONS.
Please list those persons who Do Not Have Permission to pick up your child. Please explain
the reason below or talk to the owner so she is aware of the situation.
Name: ___________________ Phone: __________________ Relationship: _______________
Reason: _____________________________________________________________________
Name: ___________________ Phone: __________________ Relationship: _______________
Reason: _____________________________________________________________________

Parent/Guardian: ______________________________________________________________
Parent/Guardian Signature: _____________________________________________________
Date: _________________

Happy Earth Playschool, 131 Linda Ave, Riverhead, NY 11901, 631.779.2643