Release Form Release Form Child’s Name: * List all persons who have permission to pick up your child, including yourself. Anyone not on this list will not be allowed to pick up your child until verification has been received from you. Please always inform the teacher each day who will be responsible for picking up your child. Adults Name: * Relationship * Address * Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Home Phone Cell Phone * plus1 Add minus1 Remove St. James Preschool reserves the right to ask for identification from any of these above-listed persons. Children will not be released to anyone whose name is not listed on this form unless we have been notified by you prior to your child’s pickup. Signature * Date * If you are human, leave this field blank. Next
