Authorization for Pick-Up

As a safety precaution, before any child may be released to/from another individual, a parent/guardian must provide advanced written and dated notification to bring/pick up a child to/from a session. This form is for any individual that you authorize as safe to pick up your child. The parent/guardians listed on the intake forms are the only people authorized to pick up unless you add them to this list.

If there is an individual with a legal restraining order in place, legally preventing them from picking up your child, or who you don’t want to have any contact with your child, please note this information on the back of this form and verbally inform the art therapist of this concern. 

Additional copies of this form may be made, if necessary. Please complete this form for ANYONE who is authorized to drop off or pick up your child from the art therapy group. If someone IS NOT on the authorized list they will not be able to pick up your child .Adults must provide identification upon arrival. 

Parent/Guardian Name
Parent/Guardian Name
Child's Name
Child's Name
Authorized Adult's Name
Authorized Adult's Name
Phone
Phone
Authorized Adult's Name
Authorized Adult's Name
Phone
Phone
Authorized Adult's Name
Authorized Adult's Name
Phone
Phone