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 Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State/Province Zip/Postal Zip/Postal Home Phone Cell Phone * Add 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
