CHILD RELEASE FORM

At Parents Time Out, we take your child's safety seriously. Please complete the following form letting us know who (other than you) is authorized to pick up your child from school, and granting us permission to seek immediate medical attention for your child in the unlikely event of an emergency.

Complete child release form

Name of Child

First Name

Last Name

Parent/Guardian Name

First Name

Last Name

Provide name, relationship, and phone number of people (other than yourself) who are authorized to pick up your child

Make sure your child's teacher knows in advance that it will be someone other than you picking them up that day. Authorized persons will need to show id before staff will release your child.

Emergency Medical Release

In the event of a medical emergency, I give the staff members of Parent's time Out permission to have my child taken to the nearest hospital (Inspira Hospital, Woodbury). I furtehr authorize any tests, x-rays, or emergency treatment the doctors deem absolutely necessary in the case I cannot be released to give my personal authorization.

I hereby give my permission for emergency medical treatment for my child

I do not give my permission for emergency medical treatment for my child

PTO Child Release Form

CHILD RELEASE FORM

KEMBLE MEMORIAL UNITED METHODIST CHURCH