Student Release Authorization Form Student Name:(Required) Full Name Grade / Class(Required) TK (4 years old) KG (5 years old) 1st Grade 2nd Grade 3rd Grade 4th Grade 5th Grade 6th grade Parent/Guardian :Full Name of Parent/Guardian:(Required) Full Name Email:(Required) Primary Phone Number:(Required)Secondary Phone Number:Authorized Person #1:Full Name of Authorized Person:(Required) Full Name Relationship to Student:(Required)Primary Phone Number:(Required)Secondary Phone Number:Authorized Person #2:Full Name of Authorized Person: Full Name Relationship to Student:Primary Phone Number:Secondary Phone Number:Days/Times this person is authorized to pick up (optional):Example: Sunday–Thursday, 2:00 PM – 4:00 PMConsent(Required) I hereby authorize the above-named individual(s) to pick up my child from school. I understand that the school will not release my child to anyone not listed on this form. I accept full responsibility for keeping this information up to date with the school administration.
