Authorised Travel and Pick Up Arrangements  Sept 2021 - July 2022
Annual Consent
To ensure pupils are only picked up by authorised adults please could you provide a list of nominated people who have permission to pick up your child. We need names of additional authorised adults other than those with parental responsibilities. If one of these people arrive to pick up your child no further checks will be made.

This form supersedes any information you have given to the school previously and this form will be completed annually to ensure we have up to date information to guarantee the safeguarding of the children.

If your pick up arrangements change over the year then please notify the office.

Please notify the class teacher of any change to adhoc pick up arrangements, due to playdates, via Class Dojo (Year 1 to Year 6). Reception parents can inform the office.
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Name of child (Surname, First Name) *
Class Name *
Authorised adult 1 (for example grandparent, child-minder): please state Surname, Forename
Relationship to child:
Authorised adult 2 (for example grandparent, child-minder): please state Surname, Forename
Relationship to child:
Authorised adult 3 (for example grandparent, child-minder): please state Surname, Forename
Relationship to child:
If one of these persons is not known to the staff they may be asked for the password provided below: please state pick up password
If there are any circumstances surrounding your child's safety that you would like the school to be aware of (for example custody issues) please inform us here:
Signed: Parent/Carer
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