Sts. Peter and Paul
C.A.R.E.S. Program
AUTHORIZATION FOR PICK-UP
Child’s Name: __________________________________________
Child’s Name: __________________________________________
Home Phone: __________________________________________
LISTED BELOW ARE THE NAMES OF ADULTS WHO ARE AUTHORIZED TO PICK UP MY CHILD FROM THE C.A.R.E.S. PROGRAM:
Name: _____________________________________
Address: ____________________________________
____________________________________
Home Phone: ________________________________ Work Phone: _________________________
Relationship: ________________________________
Name: _____________________________________
Address: ____________________________________
____________________________________
Home Phone: ________________________________ Work Phone: _________________________
Relationship: ________________________________
Name: _____________________________________
Address: ____________________________________
____________________________________
Home Phone: ________________________________ Work Phone: ____________________
Relationship: ________________________________
PLEASE NOTE: In custody disputes, court ordered guardianship papers must be on file to restrict the release of your child to an undesignated parent.
THE FOLLOWING PERSON(S) MAY NOT CALL FOR MY CHILD:
Name: _______________________________________________
Relationship: __________________________________________