Authorization for Pick-up Release (by non-parent/legal guardian)

I hereby authorize any provider/staff working for Country Fun Child Care to release my child(ren) to any of the following individuals in the case that I am not able to pick them up.


Child(ren)’s Name: 

Name of Individual: 

relationship: 

Address: 

Phone#: 


Name of Individual: 

relationship: 

Address: 

Phone#: 


Name of Individual: 

relationship: 

Address: 

Phone#: