Authorized Pickup Form

First Name *	Last Name *	Email Address *
Child #1 Name *
Child #2 Name
Child #3 Name
I authorize the following people to pick up my child:
Name *	Relationship *	Phone # *
Name *	Relationship *	Phone # *
By checking this box I certify that I am in consent with all information submitted on this form *	Door Code *
Enter Word Verification in box below *