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:_______________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________
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