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Carpool / Pick-Up Authorization Form

We require a list of all persons, (family members, carpool drivers, friends, etc.) who may pick up your child from school. Please list the names and telephone numbers of those people you authorize to pick up your child. If the list changes, it is important to resubmit this form.

If an unauthorized person will be picking up your child or your child will be going home with another student, the child's parent must notify the office via email or over the phone.

Student First Name*

Student Last Name*

Person 1:

First Name

Last Name

Relationship to Child

Phone Number - -

Person 2:

First Name

Last Name

Relationship to Child

Phone Number - -

Person 3:

First Name

Last Name

Relationship to Child

Phone Number - -

Person 4:

First Name

Last Name

Relationship to Child

Phone Number - -

The first time any authorized person picks up they should come first to the office with identification. A copy of their identification will be put on file with this form and retained for the duration of the school year. Please inform the office immediately if any of the information on this form is changed before the close of the school year.

I give Litchfield Montessori School permission to dismiss my child to the above listed persons.

Parent Full Name

Parent Signature

Carpool / Pick-Up Authorization Form

Person 1:

Person 2:

Person 3:

Person 4:

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