K-6 School Pick Up Authorization Form, 21-22
This form authorizes adults to pick up your student and must be completed each year. Students will ONLY be released to adults listed below unless the school is otherwise notified.

If you would prefer to complete this form on paper, please contact the office.

PHOTO ID MUST BE PRESENTED AT TIME OF PICK UP.
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Email *
STUDENT NAMES
You may put more than one student on a form.
Student Name(s): *
Grade(s) & Teacher Name(s):
Please select one of the following:
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FULL NAME OF ADULTS AUTHORIZED TO PICK UP STUDENT
Please include parent/guardian names (if authorized to pick up).
Individuals must be 18 years or older to pick up a student.
If you have additional adults you would like to include on this form, please reach out to the main office.
1. Adults Name:
1. Days adult is authorized to pick up student
2. Adults Name:
2. Days adult is authorized to pick up student
3. Adults Name:
3. Days adult is authorized to pick up student
4. Adults Name:
4. Days adult is authorized to pick up student
5. Adults Name:
5. Days adult is authorized to pick up student
6. Adults Name:
6. Days adult is authorized to pick up student
7. Adults Name:
7. Days adult is authorized to pick up student
Electronic Signature *
A copy of your responses will be emailed to the address you provided.
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