Florence Brownstein Pre-School
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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 Information

Child's Name(Required)
Grade(Required)
Number of Adults(Required)
Adult 1's Information
Name(Required)
Max. file size: 256 MB.
Adult 2's Information
Name(Required)
Max. file size: 256 MB.
Adult 3's Information
Name(Required)
Max. file size: 256 MB.
Adult 4's Information
Name(Required)
Max. file size: 256 MB.
Agreement(Required)
MM slash DD slash YYYY
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Director

Sara Paltiel

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Address

Chabad of Port Washington
80 Shore Road, Port Washington, NY 11050

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Phone

516-767-8672

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Email:

sara@chabadpw.org

Get in Touch.

We’d love to talk more. Drop us a message!

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