Pickup Authorization Complete this form to authorize adults other than parents to pick up your child from school. If you would like to give authorization to more than four adults, please submit an additional form. If you would like to rescind your authorization at any point (due to child care changes, etc.), please submit your revocation in writing to sara@chabadpw.org. Child’s InformationChild's Name(Required) First Last Grade(Required) Toddler - 2's Nursery - 3's Pre-K - 4's Number of Adults(Required) 1 2 3 4 Adult 1's InformationName(Required) First Last Relationship to student(Required) Home PhoneCell Phone(Required)Work PhoneUpload Photo or Copy of ID(Required)Max. file size: 256 MB.Comments: (Include anything else we should know, including specific days of the week if applicable, etc.)Adult 2's InformationName(Required) First Last Relationship to student(Required) Home PhoneCell Phone(Required)Work PhoneUpload Photo or Copy of ID(Required)Max. file size: 256 MB.Comments: (Include anything else we should know, including specific days of the week if applicable, etc.)Adult 3's InformationName(Required) First Last Relationship to student(Required) Home PhoneCell Phone(Required)Work PhoneUpload Photo or Copy of ID(Required)Max. file size: 256 MB.Comments: (Include anything else we should know, including specific days of the week if applicable, etc.)Adult 4's InformationName(Required) First Last Relationship to student(Required) Home PhoneCell Phone(Required)Work PhoneUpload Photo or Copy of ID(Required)Max. file size: 256 MB.Comments: (Include anything else we should know, including specific days of the week if applicable, etc.)Agreement(Required) I authorize the above adult(s) to pick up my child from the Florence Brownstein Preschool. Signature(Required)Date(Required) MM slash DD slash YYYY
