Client Drop-Off and Pick-Up Authorization

Child's Name*

First NameLast Name

Today's Date

Date

Parent/Guardian's Signature*

NO ONE WILL BE PERMITTED TO PICK UP YOUR CHILD IF THEIR NAME IS NOT LISTED BELOW. ALL PERSONS MUST SHOW THEIR PICTURE ID IF IT IS NOT ON FILE. MAKE SURE YOU LIST ALL ADULTS EVEN IF YOU RESIDE IN THE SAME HOUSEHOLD.

Parent/Guardian:   First Name   Last Name
Cell Phone:   Area Code   Phone Number
Work Phone   Area Code   Phone Number
Home Phone   Area Code   Phone Number
Address   Street Address   Address Line 2   City   State   Zip

PERSON(S) OTHER THAN PARENT/GUARDIAN AUTHORIZED TO PICK UP YOUR CHILD

Name:   First Name   Last Name
Cell Phone:   Area Code   Phone Number
Work Phone:   Area Code   Phone Number
Home Phone:   Area Code   Phone Number
Relationship:   Grandparent   Relative   Friend

Who Can Pick Up Your Child: Only adults 18 years of age and older. In case of a last-minute change or addition, please send an email to the office with a signed and dated note authorizing your child’s release to the new person and including the dates for which permission is given. Email authorization is accepted from a parent/guardian’s email address that we already have on record. StarBright will not release clients to anyone, under any circumstance, other than those stated above. Anyone picking up students must carry a photo ID.