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XYZ
Charter
719
361/555-1234
Primary Student (Grades 1-4) Transportation
Release Authorization
School Year 20__-20__
Student Name: _______________________________________ Grade:
_________________
XYZ Charter shall
maintain a record of parents and other authorized persons to whom the child may
be released. Each parent shall provide
XYZ Charter with the final four digits of their social security number, for purposes
of security in emergency conditions.
NORMAL RELEASE PROCEDURES:
Children will be
released only to authorized persons you list on this
form. Please inform the school office in
writing promptly of any changes.
EMERGENCY PICK-UP PROCEDURE:
When emergency conditions require that a child be released
to a person not identified in the release authorization records, the School
shall require the parent's prior approval, which may be submitted by
telephone. The parent, identified for
security by the last four digits of the social security number, shall designate
the person to whom the child may be released.
The person to whom the child is to be released must in turn provide the
parent's four digit number as identification, present their driver's license
for the number to be recorded, and sign the "Child Pick-Up
Authorization" form which shall be retained by the XYZ Charter School.
If an individual whom you have not listed on this form is to
pick up your child, you must:
1. Inform the school
office and identify the authorized individual;
2.
Provide this individual with the last four digits of your social security
number and inform them that they must show their driver's license, and
3.
Have this individual come into the office; provide a driver's license and the
last four digits of your social security number.
Without this information, your child will not be released.
FOR PARENTS WHO ARE
DIVORCED:
In
the case of a divorce, it shall be the responsibility of the one who is granted
primary custody or possession of the child (being the one with whom the child
primarily lives) to provide the XYZ Charter School with a copy of the custody
decree or agreement. It shall be the
responsibility of a parent to notify the XYZ Charter School immediately if the
parent or any other person has been placed under a protective order,
restraining order, or other order of a court or agency, which order prohibits
or restricts that parent's or other person's access to or possession of the
child, and a copy of any such order should be provided to XYZ Charter
immediately.
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ACKNOWLEDGMENT BY PARENT(S) (To be completed
by all parents)
Each parent or guardian of the above named child, by his or
her signature herein below, acknowledges and certifies that he/she has read and
fully understands and agrees with the above and foregoing information and
procedures concerning release of the child.
Name (Last, First)
__________________________________ SSN _____________________
Parent/Guardian Signature _____________________________________________________
Relationship to Student ¨ mother
¨ father
¨ step-mother
¨ step-father
¨ other
Name (Last, First)
_________________________________ SSN ______________________
Parent/Guardian Signature _____________________________________________________
Relationship to Student ¨ mother
¨ father
¨ step-mother
¨ step-father
¨ other
The
following people are authorized to transport my child to and from school:
Name:
(Last, First) ____________________________ Phone _________________________
Name:
(Last, First) ____________________________ Phone _________________________
Name: (Last, First) ____________________________
Phone _________________________
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