The Lebanon Lantern The Lebanon Lantern Spring 2019 | Page 15

EMERGENCY CONTACTS AND PICK UP AUTHORIZATION
Child’s Name ________________________________________________
Please list all person authorized to pick up your child. Parents or guardians must be included on this list. No child will be
released without the person picking the child up being on this list. NO exceptions will be made to this policy. This done for
the safety of your child. Please make sure that the individuals on this list are aware that they may be called in an emergency
to pick up your child. You are welcome to add or delete from this list at any time. Please indicate if the non-custodial
parent has limits on visitation or pick up. If a non -custodial parent has been denied visitation or has limited visitation by
court order, a copy of the order must be given to the program director and kept on file.
Child:_________________________________________________________________________
Parent Name:___________________________________________________________________
Address: _____________________________________________________________________________
Home Phone: ________________ Cell Phone: _______________________ Work Phone: ____________
Relationship to Child: ___________________________________________________________________
Emergency contact #1: _______________________________________________________________________________
Address: _____________________________________________________________________________
Home Phone: ________________ Cell Phone: _______________________ Work Phone: ____________
Relationship to Child: ___________________________________________________________________
Emergency contact #2: _______________________________________________________________________________
Address: _____________________________________________________________________________
Home Phone: ________________ Cell Phone: _______________________ Work Phone: ____________
Relationship to Child: ___________________________________________________________________
Please make sure at least one of the emergency contacts is available at all times while your child is at Park School. In
the event of an emergency, parents will be contacted. If not available, the other individuals on the emergency contact
/ Pick up list will be contacted.
Parent / Guardian Signature: ______________________________________
Date: ______________