Pick Up Authorization





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Sandpiper Montessori Preschool

Child release Authorization Form 2016-2017


Student Name:


Date:


Parent Guardian Name: Checking this box is equal to your hand signature.

The following individuals are authorized to pickup our child/ren:
1. relationship:

2. relationship:

3. relationship:

4. relationship:


The following individuals are NOT permitted to pickup our child/ren:


1. relationship:

2. relationship: