Student ____________________ Grade:_______ Teacher: _____________

Who is authorized to pick up your child from school?

Permission to Release Child to Alternate Adult

Inspired Teaching School staff will not release your child to an unauthorized person. No one other than the legal

parent or guardian may pick up your child unless listed below. Please provide the names of any individuals

(including relatives or other Inspired Teaching parents) that have permission to pick up your child. Update this

list as needed throughout the year. If there is someone besides a parent who might pick up your child in an

emergency, please be sure to provide this authorization below.

I ________________________________, give permission to release my child to the following adult(s):

Name Relationship to Student Daytime Phone

If you have concerns that an individual who is not authorized may try to pick up your child, please notify the principal (Zoe Duskin: Lower School; Latisha Coleman: Upper School)

Parent/Guardian Name: _______________________________________________________________

Parent/Guardian Name: _______________________________________________________________

Parent/Guardian Phone Number(s): ______________________________________________________

Parent/Guardian Email Address: ________________________________________________________

_______________________________________

Parent Name (please print)

_________________________

Parent/Guardian Signature Date

*To Update the Authorized Pick Up List, Families MUST complete this form for each addition or

subtraction. Copies of this form can be found and returned to the front desk. *