General Release Form
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2Warren W. Cherry Preschool...1418 Lake Street...Evanston, Illinois 60201...(847) 492-1213
General Release Form
Revised 7/13
Name of Child ________________________________________
Date ______________________
AUTHORIZATION FOR RELEASE
The following people (please include parents/guardians) are authorized to pick up my child from Cherry Preschool:
Individuals must be at least 18 years of age to pick up a child from preschool per DCFS regulation.
Name:
Relationship: Parent/Guardian (legally responsible for child)
Address:
Phone:
Cell:
Name:
Relationship: Parent/Guardian (legally responsible for child)
Address:
Phone:
Cell:
Name:
Relationship:
Address:
Phone:
Name:
Relationship:
Address:
Phone:
Name:
Relationship:
Address:
Phone:
Name:
Relationship:
Address:
Phone:
Name:
Relationship:
Address:
Phone:
Name:
Relationship:
Address:
Phone:
Name:
Relationship:
Address:
Phone:
Name:
Relationship:
Address:
Phone:
PLEASE ATTACH ANOTHER SHEET IF THERE ARE
ADDITIONAL NAMES.
_______________________________________________
Signature of Parent/Guardian
Only the people whose names appear on this list are
authorized to pick up your child. Teachers may request
identification and will not release your child to anyone not
_______________________________________________
authorized by you.
Date
(TURN OVER & COMPLETE BACK SIDE
)
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