Happy House Daycare Alternate Pick-Up Authorization Form Phone 780.594.3933 Email lawuta@telus.net Children _________________________________________________________________________________________________________ Child’s Name DOB r Full Day rHalf Day _________________________________________________________________________________________________________ Child’s Name DOB r Full Day rHalf Day Authorized Individuals You do not need to include parents or legal guardians on this form. For additional authorizations, please use the back of this form 1._______________________________________________________________________________________________________Adult’s Name Relationship _________________________________________________________________________________________________________ rTRY 1St Work Phone rTRY1ST Home Phone rTRY 1ST Cell Phone 2._______________________________________________________________________________________________________ Adult’s Name Relationship _________________________________________________________________________________________________________ rTRY 1ST Work Phone rTRY 1ST Home Phone rTRY 1ST

Cell Phone

3._______________________________________________________________________________________________________ Adult’s Name Relationship _________________________________________________________________________________________________________ rTRY 1ST Work Phone rTRY 1ST

Home Phone rTRY 1ST Cell Phone

Authorize all individuals listed on this form (front and backside) to pick up my child (ren) from Happy House Daycare. All information is provided is correct to the best of my knowledge. Signature of Parent or Guardian: _________________________________________________________________________________________________________

Date Signed:

Created on June 27,2012