I GIVE MY PERMISSION FOR THE FOLLOWING PERSONS TO PICK UP MY CHILD.

Name:__________________________________Relationship:_______________________________

Address:________________________________Phone: (______)_____________________________

Name__________________________________ Relationship:_______________________________

Address:________________________________Phone: (______)_____________________________

Name:__________________________________Relationship:_______________________________

Address:________________________________Phone: (______)_____________________________

Name: ________________________________ Relationship________________________________

Address: _______________________________ Phone: (______)____________________________

Parent / Guardian Signature: ____________________________________ Date: _____/_____/______

o I have no objections to the use of photographs of my child for educational and / or promotional purposes.

Where did you hear of our center?
____________________________________________________________________________________

Is there anything you feel that we should know about your child in order to further our understanding?

COMMENTS:_______________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________