Student Pickup Permission Form | Walnut Grove Christian School

Student Pickup Permission Form

In an effort to provide a safe environment for your child at all times, please list the names of people authorized to pick up your child at the end of school. We would also like you to list anyone that you absolutely do not want picking up your child. This list will be kept in your child’s file and referenced in the future if you are not in the car pool line at 2:45pm and someone else asks for your child.
Person #1 (other than parents) authorized to pick up my student(s):
Relationship to student of Person #1 authorized to pick up my student(s):
Person #2 (other than parents) authorized to pick up my student(s):
Relationship to student of Person #2 authorized to pick up my student(s):
Person #3 (other than parents) authorized to pick up my student(s):
Relationship to student of Person #3 authorized to pick up my student(s):
Person #4 (other than parents) authorized to pick up my student(s):
Relationship to student of Person #4 authorized to pick up my student(s):
Person #5 (other than parents) authorized to pick up my student(s):
Relationship to student of Person #5 authorized to pick up my student(s):
Names of people who MAY NOT pickup your child:
This digital signature is legally binding according to the federal ESIGN Act of 2000. Your computer IP address and the date will be captured.