Student Pickup Authorization

Lists the adults authorized to pick a student up from school, with relationship and contact info.

Student Pickup Authorization

Please list the adults, other than yourself, who are authorized to pick up your child from school. This ensures your child’s safety and helps us keep accurate records.
Student’s Full Name*

Authorized Adults

Please provide details for adults authorized to pick up your child. They may be asked for photo ID.
Adult 1 Full Name*
Adult 1 Relationship to Student*
Adult 1 Phone Number*
Adult 2 Full Name
Adult 2 Relationship to Student
Adult 2 Phone Number
Adult 3 Full Name
Adult 3 Relationship to Student
Adult 3 Phone Number

Parent/Guardian Confirmation

Parent/Guardian Full Name*
First
Last
Date*

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