Special Consent Pick Up

Child's Daycare Room: *

Date & Time

To use this form, person must be at least 18 years old *

I confirm the person listed above is at least 18 years old

Parent's First & Last Name: *

Address (should match ID)

SPECIAL CONSENT FORM FOR PICK UPS

The person above can be added to my anytime pick up list:

Yes

They can be reached by phone at:

Will be picked up by (full name): *

This form is for authorizing a one time pick up of your child,

or for adding people to your child's pick up list.

Individuals must be over 18 years of age.

It is NOT to be used for same day pick-ups.

You will be contacted by the daycare to confirm the information submitted.

Back to Current Families

* indicates mandatory field

Child's First & Last Name: *

Message:

Email: By entering in my email I release Jackman Community Daycare from any & all liability and waive all claims to any & all damages whatsoever & however caused, because the Daycare permitted my child to leave the Daycare in accordance with the permission I have granted above. *