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Authorized Escorts List Form

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Authorized Escorts List Form

The New York City Health Code requires child care centers to obtain and maintain, for every child, a list of all

persons authorized by the parent/ guardian to escort the child from child care. The child care center shall not

release any child to any individual who has not been identified by the parent/ guardian as a person who is

authorized to escort a child out of the center.

Instructions: The parent/ guardian must complete, sign, and return this form to the child care center upon

enrollment and update this form immediately when there is any change in authorized escort information.

I, ______________________________________, authorize this child care center to release my child,

(parent/ guardian name)

________________________________________, to the individuals I have identified below.

(child name)

Name:

Relationship to child:

Home address:

 Mobile/Cell Telephone

 Home Telephone

 Work Telephone

Preferred contact:

 Text (Mobile)

 E-mail

Mobile/Cell:

Telephone:

Home:

Work:

E-mail:

Name:,

Relationship to

child:,

Home

address:,

 Mobile/Cell Telephone

 Home Telephone

 Work Telephone

Preferred

contact:,

 Text (Mobile)

 E-mail

Mobile/Cell:

Telephone:,

Home:

Work:

E-mail:,

Parent/ Guardian Signature:

____________________________________________________________

Date:

_________________________________________________________________________________

In accordance with the requirements of the New York City Health Code, Article 47, Section 47.57(h)(1) child care centers must obtain and maintain for every child a list of the

name, relationship to child, address and contact information of every person the parent has authorized to escort a child from the child care service. The permittee shall not

release any child to any individual who has not been identified by the parent(s)/guardian(s) as a person who is authorized to escort a child out of the service.

Authorized Escorts List Form

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