Authorized Pick-Up

Site Based: Pick-up Authorization form

Student Name*
First Last
School Name*
Parent/Guardian full name*
Address*
Street Address City ZIP / Postal Code
Email*
Enter Email Confirm Email
Phone*
We provide a small healthy snack to children in our after school programs. Does your child have any specific medical conditions, dietary restrictions, allergies or other concerns we should know about? Please describe**
AUTHORIZED PICK-UP INFORMATION
The following is required to ensure your child safety. Please choose one of the following:*
- My child is allowed to walk home on their own
- MY child is NOT allowed to walk home on their own. They will be picked up from the after school program by their parent(s)/guardian(s) or other authorized person.
Authorized Pick-Up*
I give permission to the following individual(s) to pick up my child from the Big Brothers of Greater Vancouver mentoring program. I have informed these individual(s) of the pick-up policy (see next page) and that they must present government-issued photo ID in order for my child to be released.

Your child(ren) will not be allowed to leave the site with anyone other than those listed below. You can remove or add people to this list at any time by contacting your Mentoring Coordinator and signing an updated Authorized Pick-Up Form.
I have read, understand, and accept the above agreement.
Authorized pick-up person #1
Full Name
Relationship to Child
Phone
Alternate Phone
Authorized pick-up person #2
Full Name
Relationship to Child
Phone
Alternate Phone
ABSENT CHILD POLICY & PICK-UP POLICY
Absent Child Policy*
Parents/guardians are responsible for informing the Mentoring Coordinator if their child will be absent from the program.
I have read, understand, and accept the Absent Child Policy.
Pick-Up Policy*
Parents/guardians or authorized pick-up person(s) must pick up their child at the program end time.

a) The Mentoring Coordinator will call the guardian and/or authorized pick-up person(s) if the child was not picked up within 15 minutes of the program ending.

b) If the guardian and/or authorized pick-up person(s) is unreachable, the Mentoring Coordinator will call the emergency contact within 30 minutes of program ending.

c) Consistent late pick-ups may result in the child being withdrawn from the program.
I have read, understand, and accept the Pick-Up Policy.

Save and Continue Later

Authorized Pick-Up

Site Based: Pick-up Authorization form

AUTHORIZED PICK-UP INFORMATION

ABSENT CHILD POLICY & PICK-UP POLICY

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