Creative learning for children ages 3-13
July 3 - 28, 2017

Online Pick-Up Authorization Form

Important: Please fill out and submit this form in order to complete the registration process for your child(ren).

NOTE:  Submit this completed form back to us no later than June 15.

ONE SIGNATURE is required (pick-up authorization section).  Note the "X" where your signature is required.  Forms not signed will be returned.

Complete all sections of this form. If you have any medication, an epipen, inhaler or any other special item for your child, please be sure to fill out the allergy form found here.

Child(ren)'s Last Name

Child's Name Birthdate
Child's Name Birthdate
Child's Name Birthdate
Child's Name Birthdate
Complete Address
Home Phone

Pick-up Authorization

NOTE:  Parent signature required even if parent(s) is/are only person/people authorized to pick up child(ren).

The person (people) authorized to pick up my child(ren) is (are) (include child's parents):

Parents:                   

Other Authorized Person(s)

X
Parent Signature (required) Date

Your typed name is considered your signature.