Back to Forms List Consent & Release Name of Facility Address of Facility Name of Child The following persons are allowed to pick up my child from child care in the event that I am unable to: Name Phone Relationship Name Phone Relationship Name Phone Relationship Anyone NOT permitted to pick up my child (deliver copy of court order to facility, if applicable): Name Phone Relationship Name Phone Relationship Consent is given for the items marked below: Walking Trips Yes No To the following: Motor Vehicle Trips Yes No Type of vehicle: To the following: Child restraint system to be used: Special needs of child during transport: Daily Transportation Yes No Type of vehicle: To the following: Child restraint system to be used: Special needs of child during transport: Swimming and/or Wading Yes No Location: Other Activities (e.g. homework supervision, trips to neighborhood playgrounds, special trips) Yes No Description: Consent to Photo Release Yes No If yes, my child may be photographed while in child care. Photos may be used in newspapers or other media for the purpose of publicity or shared with other families whose children attend the child program. If no, my child shall not be photographed while in the child care program. Signature of Parent Date Captcha Submit If you are human, leave this field blank. Δ
