B4-YOUTH PICK-UP AUTHORIZATION FORM

Select Youth Group Below
I authorize the persons listed below to pick-up from the youth initiatives program. For my child’s safety, I understand that all authorized persons on the list below will be asked to show photo identification before my child is released to them; therefore, I will notify all authorized persons of this requirement so that they will have photo identification with them when they arrive to pick up my child. (Please include parents/guardians names)
Parent/Guardian Name Parent/Guardian Name First Last
Participant Name Participant Name First Last
(Note: If giving permission for the youth to sign themselves out, please list their name below.)
Name Name First Last
Relationship
Cell Phone Cell Phone - ### - ### ####
Home Phone Home Phone - ### - ### ####
Work Phone Work Phone - ### - ### ####
Name Name First Last
Relationship
Cell Phone Cell Phone - ### - ### ####
Home Phone Home Phone - ### - ### ####
Work Phone Work Phone - ### - ### ####
Name Name First Last
Relationship
Cell Phone Cell Phone - ### - ### ####
Home Phone Home Phone - ### - ### ####
Work Phone Work Phone - ### - ### ####
Name Name First Last
Relationship
Cell Phone Cell Phone - ### - ### ####
Home Phone Home Phone - ### - ### ####
Work Phone Work Phone - ### - ### ####
Name Name First Last
Relationship
Cell Phone Cell Phone - ### - ### ####
Home Phone Home Phone - ### - ### ####
Work Phone Work Phone - ### - ### ####
Name Name First Last
Relationship
Cell Phone Cell Phone - ### - ### ####
Home Phone Home Phone - ### - ### ####
Work Phone Work Phone - ### - ### ####
By signing below, I verify that I have read and agree to the Student Pick-Up policies described above and authorize the Chapter to release my child to the persons listed above. I also agree to notify the Chapter in writing of any changes to the above list of authorized persons.
Draw your signature into the box below.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Date Date / MM / DD YYYY

B4-YOUTH PICK-UP AUTHORIZATION FORM

B4-YOUTH PICK-UP AUTHORIZATION FORM

(Note: If giving permission for the youth to sign themselves out, please list their name below.)

By signing below, I verify that I have read and agree to the Student Pick-Up policies described above and authorize the Chapter to release my child to the persons listed above. I also agree to notify the Chapter in writing of any changes to the above list of authorized persons.