Authorization to Sign Out Form

I ______________________________________ request permission for the following person's) to be able to pick up my daughter/son in case of an emergency, due to sickness, health conditions, or appointment.

First Person Contact Information

First Name
Last Name
Middle Initial
Street Address
Address (cont.)
City
State
Zip/Postal Code
Work Phone
Home Phone

Relationship

2nd Person Contact Information:

First Name
Last Name
Middle Initial
Street Address
Address (cont.)
City
State
Zip/Postal Code
Work Phone
Home Phone

Relationship:

3rd Person Contact Information

First Name
Last Name
Middle Initial
Street Address
Address (cont.)
City
State
Zip/Postal Code
Work Phone
Home Phone

Relationship

Signature of Parent/Guardian

Date: