Preschool/daycare Student Registration Form Page 2

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Revised May 2016
Emergency Contact
Name:_____________________
Relationship to child: ________________________
Home Phone: _______________
Work Phone: _______________________________
Cell Phone: ________________
Authorization for pickup
Your child will only be released to an authorized person listed on this form in the
parent/guardian and/or emergency contact sections of this form. Please indicate the name,
address and phone number of any other person(s) who you authorize to pick up your child on
your behalf.
Name
Address
Phone #
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
A parent/guardian’s verbal authorization must be received before your child will be released to
anyone not listed here. If not received, and you cannot be contacted by phone, your child will
not be released
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