Pick-Up/drop-Off Authorization Form

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Pick-Up/Drop-Off Authorization Form
(Non-parents)
I, ___________________________________________ (PRINT parent’s name) authorize those indicated
below to pick up and/or drop off _________________________________ (Please PRINT child’s name),
at HudsonWay Immersion School on the basis indicated below.
Parent Signature _______________________________________________ Date ___________________
Name:_______________________________ Relationship to child:_____________________________
Pick Up
Drop Off
Phone (optional): _____________________
Once (mm/dd/yy): _____________
Always
I cancel this authorization: _______________________________________________________________
Parent Signature
Date
Name:_______________________________ Relationship to child:_____________________________
Pick Up
Drop Off
Phone (optional): _____________________
Once (mm/dd/yy): _____________
Always
I cancel this authorization: _______________________________________________________________
Parent Signature
Date
Name:_______________________________ Relationship to child:_____________________________
Pick Up
Drop Off
Phone (optional): _____________________
Once (mm/dd/yy): _____________
Always
I cancel this authorization: _______________________________________________________________
Parent Signature
Date
PLEASE NOTE: Additional authorizations may be added at any time. Please see the Office Manager to
add to this form or request a new form.
175 Riverside Blvd. New York, NY 10069 • (O) 212-787-8088 • (F) 914-357-2988 •

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