Family And Child Education & Support 育才之家

Alternate Pickup Authorization

Use this form to let us know when someone other than the registered guardian will pick up your student.

Requests must be submitted before the pickup time. Bring ID at pickup.

Guardian Contact Parent/Guardian Full Name Parent/Guardian Email Parent/Guardian Phone

We will contact this number if we need clarification.

Student Information Student Name

Grade

Teacher / Class

Authorized Pickup Adult Authorized Adult Full Name Relationship to Student Authorized Adult Phone ID / Verification Note

Pickup Schedule Date(s) & Time(s)

List each day and time this adult is authorized to pick up.

Pickup Location / Instructions Reason (optional)

Confirmation Additional Notes I confirm that I am a registered guardian and authorize the person named above to pick up my student for the dates listed.

You will see a confirmation message below.