K-6 School Pick Up Authorization Form, 22-23
This form authorizes adults to pick up your student and must be completed each year. A form will need to be completed for each student, and 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 at 518-668-5714.

PHOTO ID MUST BE PRESENTED AT TIME OF PICK UP.
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Email *
Student Name:
Please complete one form for each student.
 *
Grade: *
Teacher: *
Please select one of the following:
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FULL NAME OF ADULTS AUTHORIZED TO PICK UP STUDENT
Please list all adults authorized to pick up your student regardless of their regular dismissal procedure. If your student takes the bus regularly we will still need a pick up authorization.
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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