The New Village - AUTHORIZATION TO RELEASE/PICK-UP STUDENT

AUTHORIZATION TO RELEASE/PICK-UP STUDENT

For use during enrollment at the New Village School.
All students should have at least two people authorized to pick them up from school in case the parents are unable to, or in the case of an emergency
Number of Students*
Student 1 Name*

First NameLast Name
Student 2 Name*

First NameLast Name
Student 3 Name*

First NameLast Name
Emergency Contact 1
Emergency Contact 1 Name*

First NameLast Name
Emergency Contact 1 Cell Number*
Please enter a valid phone number.
Email*
example@example.com
Emergency Contact 1 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact 2
Emergency Contact 2 Name*

First NameLast Name
Emergency Contact 2 Cell Number*
Please enter a valid phone number.
Email*
example@example.com
Emergency Contact 2 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I understand that school faculty or staff may take my child home if I am unable to, or in the case of an emergency.
Please check the following box if you would like parents of the New Village School to pick up your child

Yes, I give your permission for my child(ren) to be released to any parent or guardian of any childenrolled in the New Village School. The parent picking up my child will coordinate directly with me.
Should be Empty:

AUTHORIZATION TO RELEASE/PICK-UP STUDENT