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Pick-Up Authorization Form

Pick-Up Authorization Form

General Information

(hereafter "Program")

Help Text

(hereafter "Participant")

Please fill out either Section I or II.


Please list any individual who is authorized to pick up the Participant, including yourself. Each authorized person must be at least 16 years of age. The above-named Participant will not be permitted to leave the Program with anyone who is not listed below. Authorized individuals must pick up Participants in person and may be requested to show identification to Program staff when picking up a Participant. Participants will not be released to persons who fail to provide acceptable identification upon request.

I authorize the following responsible person to pick up the Participant from the aforementioned Program activities:



The following individuals are not permitted to pick up the Participant:

Signature here.


The Participant is at least 16 years of age and will be responsible for his/her own transportation to and from Program. The Participant may sign him/herself in at the start of Program activities and sign him/herself out at the end of Program activities.

Signature here.