Lowpoint-Washburn C.U.S.D. #21

21^st Century Community Learning Center Grant

After-School Program

RELEASE FORM

Dear Parents:

Attached is a form to list all persons you authorize to pick up your child.  Please include yourselves on the sheet.  The parent(s) must sign it.  If you wish to add to this list, you must add the name/names to the initial sheet.  You cannot call us to have names added.  (All names of people picking up a child must be in the parent’s writing.)  We cannot accept calls from someone picking up your child unless they are on the authorized list.

For the safety of the children enrolled in the after-school program, the staff will ask for a photo-identification from any persons who arrive to pick up your child.

Please give a lot of thought to person you wish to have on your list.  We can always delete a name if it no longer applies.

Persons authorized to pick up _______________________________________________

                                                                        Child’s Name

                        Names                                                                                    Phone Numbers

1.      _____________________________________________________________________

2.      _____________________________________________________________________

3.      _____________________________________________________________________

4.      _____________________________________________________________________

5.      _____________________________________________________________________

6.      _____________________________________________________________________

Date                                                                             Parent’s Signature

Website Contact: Valerie Kruzan

Updated on May 1, 2012