Day(s)/Date(s) Approved for :____________________ |
I hereby authorize Kids’ Kingdom to release my child to the following person on the day(s) and date(s) listed above.
Name:__________________ Relationship to Child:_______________
Home Address: ___________________________________________
Home Phone: ________________ Cell Phone: __________________
Work Place: ___________________ Work Phone: ______________
Work Address: __________________________________________
I have supplied Kids’ Kingdom with a photograph attached, labeled with their name on the back. (if a group picture, please clearly mark the correct face.)
I understand that this is NOT a Standing Authorization and is only valid for the DAY(s) NOTED.
I understand that the authorized person’s picture will be returned to me the next day. I also understand that whenever I want this person to be authorized to pick up my child in the future that another “ONE TIME ONLY” Authorization for Dismissal for will need to be completed.
_________________________________ ______________ Parent/Gurdian's Signature Date
_________________________________ ______________ Provider's Signature Date
THIS FORM EXPIRES AFTER THE APPROVED DAY(s)/DATE(s) NOTED AT TOP OF FORM. 2006.003