PICK-UP/RELEASE FORM by L3DWv62W

VIEWS: 6 PAGES: 1

									                 DELTA SIGMA THETA SORORITY, INC.
                  SOUTHFIELD ALUMNAE CHAPTER

                                PICK-UP/RELEASE FORM


Students are to be dropped off and picked up promptly at Morris Adler Elementary School.
Students must be signed in and out of tutoring. Delta Sigma Theta Sorority Inc., does not
provide supervision before or after tutoring. If a student has not been picked up within five (5)
minutes of the end of his/her tutorial session, the student will remain in the library and there will
be a $1.00 per minute late pickup charge to be paid immediately upon pick up. Late pickup is
not offered as an option; it may jeopardize your child’s future attendance.

Student ________________________________________________________________

Mother’s Name __________________________________________________________
Home Phone ____________________________ Cell Phone ______________________

Father’s Name ___________________________________________________________
Home Phone ____________________________ Cell Phone ______________________

My child, named above, has my permission to be picked up by person(s) listed below. I
understand my child cannot be picked up from Morris Adler Elementary School by anyone
except his/her guardians unless they are on this list. Note: All persons authorized to pick up
students must be at least 16 years of age. Please inform everyone approved by you on this
release that they must have a photo ID before the child will be released into their custody.

Name _________________________________Relationship______________________
Address _________________________City _____________ State ___ Zip ___________
Home Phone ____________________________ Cell Phone ______________________

Name _________________________________Relationship______________________
Address _________________________City _____________ State ___ Zip ___________
Home Phone ____________________________ Cell Phone ______________________

By signing this form, I acknowledge that I have read all of the above information related to
picking up my child from tutoring. I have instructed my child that he/she is to leave with no one
unless listed above.


Print Name __________________________Signature ____________________________


Date ___________________________

								
To top