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2023-24 Authorization to Pick Up Form

Student's Name*

Answer Required

Current Grade*

Answer Required

Name of Parent(s)/Guardian(s)

Answer Required

Home Phone

Answer Required

Cell Phone

Answer Required

Work Phone

Answer Required

To allow adults other than the parents/guardians to pick up children, we must have their names on record in the office. If we are unfamiliar with a person picking up your child, we may ask for identification.

Additional authorized persons to pick up student listed above:

Name

Answer Required

Relationship to Student

Answer Required

Cell Phone

Answer Required

Additional Phone

Answer Required

Name

Answer Required

Relationship to Student

Answer Required

Cell Phone

Answer Required

Additional Phone

Answer Required

As legal guardian of the student listed above, I authorize the additional person(s) to pick up my child from the Premier Arts Academy.

Answer Required

YES

Confirmation Email

Confirmation Email *

Email Required